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THE CATARRHAL AND 
SUPPURATIVE DISEASES 

OF 


THE ACCESSORY SINUSES 
OF THE NOSE 

By 

ROSS HALL SKILLERN, M.D. 

Professor of Laryngology Medico-Chirurgical College, Post-Graduate School of Medicine, Uni¬ 
versity of Pennsylvania; Late Lieutenant-Colonel, M.C.U.S.A.; Fellow of American 
Laryngological Association; Fellow of the American College of Surgeons; 

Fellow of the American Laryngological, Rhinological and Oto- 
logical Society; Fellow of the American Acadamy of 
Ophthalmology and Oto-Laryngology; Fellow 
of the College of Physicians, 

Philadelphia; etc., etc. 

300 ILLUSTRATIONS 

FOURTH EDITION, THOROUGHLY REVISED AND ENLARGED 



PHILADELPHIA W LONDON 

J. B. LIPPINCOTT COMPANY 







Copyright, 1913, By J. B. Lippincott Company 
Copyright, 1916, By J. B. Lippincott Company 
Copyright, 1920, By J. B. Lippincott Company 
Copyright, 1923, By J. B. Lippincott Company 


Electrotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, TJ. S. A. 


QCl 2^ '^23 



PREFACE TO FOURTH EDITION 


The study of the Accessory Sinuses has ceased to be regarded 
as a specialty within a specialty but has now become definitely 
recognized as an integral part of rhinology. It has not been long 
since the term laryngology embraced everything pertaining to 
the upper air passages and a Laryngologist was a specialist who 
treated affections of the nose, throat and appendages. The term 
Ethnologist then came to designate one who specialized in diseases 
of the nose and now Sinuology and Sinuologist are recognized 
entities in the vocabulary of medicine. In revising the previous 
edition, as nothing revolutionary in sinuology had occurred, the 
thought was to improve the new edition more by a process of re¬ 
fining rather than accretion and with this in mind the description of 
the methods which have been successful have been augmented while 
the procedures which have proven impractical and matter which 
had become obsolete have been deleted. Certain illustrations have 
been treated likewise, notably certain instruments while the Denker 
method on the maxillary sinus is depicted in steps instead of the 
previous single illustration. Additions have been made to many 
important sections which represent the latest ideas and opinions 
of mainly American investigators; in short it has been our 
endeavor to make this edition the collaboration and digest of more 
important studies on sinuology up to the present writing. 





























































































































































PREFACE TO THIRD EDITION 


Since the appearance of the second edition of this work some 
three years ago, the medical world of Europe has been so convulsed 
by the great conflict of nations that little which did not pertain to 
war surgery (at least as far as our subject was concerned) found a 
place of publication. Even before the United States entered the 
struggle the effects of the war were felt to such an extent in our 
country as to discourage scientific research in medicine by the very 
tenseness of the times, and after the die was cast, the medical pro¬ 
fession as a whole devoted itself to the successful furtherance and 
eventual termination of the war. During this period but little was 
thought of or accomplished in this country except to improve the 
general condition of the recruit, in order to fit him for the physical 
and mental hardships incident to combat service, while behind the 
lines of battle it was the surgical reconstruction of the human parts 
torn by shot and shell. Much was learned through both these activi¬ 
ties. While in the service, the author was particularly interested in 
the influence of diseased sinuses on the general system, especially 
the amount or degree of incapacity produced in the individual and 
later, while with the American Expeditionary Forces, with the in¬ 
juries and wounds of the sinuses themselves. These, as far as they 
are of interest in civil life, have been incorporated in the new edition 
as well as additions of new treatments and surgical procedures 
which have proven of sufficient merit. 







PREFACE TO SECOND EDITION 


It is with no small sense of gratification, when one compiles a 
work, to note that his colleagues have placed their approval upon 
his efforts. This treatise was printed to supply a work on the 
sinuses of the nose in the English language, but it was not antici¬ 
pated that the first edition would so speedily become exhausted. In 
the interim, however, much has intervened, many corrections had 
to be made and not a little new matter to become incorporated. The 
greater part of the changes consist of amplification, of which the 
most important are the following: 

The treatment of sinus disease in children; the use of the naso- 
pharyngoscope in diagnosis of obscure conditions in the posterior 
ethmoid and sphenoid region; the diagnostic needle puncture of the 
maxillary sinus more fully explained, with possible dangers and 
how to avoid them; Canfield’s operation on the maxillary sinus 
compared with the preturbinal method, with instructions for and 
illustrations of both the immediate and ultimate effects of opera¬ 
tions on the sinuses; a compilation of the American mortalities fol¬ 
lowing the Killian operation on the frontal sinus; complete revision 
of the chapter on the sphenoid sinus, with description and illustra¬ 
tions of Halle’s new operation; a chapter on combined empyema or 
multiple sinusitis, etc. In addition to this, the entire work has 
undergone a systematic revision. Certain statements which seemed 
obscure have been rearranged and amplified with especial reference 
to their clarity. 

Considerable attention has been given to that phase of the treat¬ 
ment which deals with the judgment of the attending surgeon as to 
what procedures shall be followed under different circumstances, 
such as the proper moment to operate and what form of operation is 
indicated. This is especially discussed in connection with the 
maxillary and frontal sinuses. 

The after-treatment of sinuses upon which an operation has 
been performed, a subject which has hitherto been almost neglected, 
is also thoroughly discussed, with measures to meet any untoward 
complication that may arise. 

I am especially indebted to my friend and classmate, George 

vii 



PREFACE TO SECOND EDITION 


viii 


Morrison Coates, M.D., for liis thorough review and correction of 
the initial work, as well as for his many wise suggestions for the 
betterment of this edition. 

In conclusion, I wish to express my appreciation for the friendly 
manner in which the work has been received by my colleagues, and 
especially to those reviewers who in their kindness have possibly 
permitted their friendship to prejudice their better judgment (Am. 
Jour. Med. Sciences, Interstate Med. Jour., Central, fur 
Laryngologie). 


PREFACE 


Dubing courses of teaching the treatment of accessory sinus 
diseases very frequently students have made inquiry regarding 
the proper handbook to aid their studies in this direction. 

In the German language Hajek and Zarnico would instantly 
rise to the minds of the well-equipped teacher as admirable works, 
both from the viewpoint of scientific accuracy and that of prac¬ 
tical application. 

In the French language Luc, and Sieur and Jacob, have con¬ 
tributed works of decided merit. 

In the English language Logan Turner has displayed a com¬ 
mendable spirit of research and has collected much valuable in¬ 
formation of a general character, but it cannot be claimed that 
his work is adaptable as a general text book. 

Several excellent works of American and English authors, 
embracing the Nose, Throat and Ear as a whole, have appeared, 
but their general scope has not permitted the consideration in 
minute detail of nasal accessory sinus disease. 

To set forth in the English language a thorough and exclusive 
treatment of this subject has been the inspiration of this work. It 
will be noted that repetitions occur in several places. These have 
been intentional, not only to thoroughly impress these parts on 
the mind of the student, but to obviate the necessity of continually 
referring to other portions. 

Extensive references have been made and every effort has been 
exerted to give credit where it belongs, nevertheless errors of omis¬ 
sion and commission must necessarily have crept into a book of 
this description. I trust that my American colleagues will apprise 
me of any such that may come under their notice. In collabora¬ 
tion of this work I have been ably assisted by Messrs. E. F. and 
Ludwig Faber, Erwin Faber making the anatomical illustrations 
and Ludwig Faber the operations. Several of the rarer anomalies 
have been drawn from specimens prepared by Dr. M. H. Cryer 
and kindly loaned to me for this purpose. I am also greatly 
indebted to George F. Martin, M.A., for his painstaking and thor¬ 
ough revision and in many instances correction of the manuscript. 






CONTENTS 


PART I. 

GENERAL CONSIDERATIONS. 

PAGE 

Examination of the Nose for Sinus Disease. 1 

Anatomy of the Lateral Wall of the Nose. 3 

Basic Structure of the Lateral Nasal Wall. 4 

Anatomy of the Nose in Frontal Section. 13 

Topographical Anatomy of the Hiatus Semilunaris. 17 

Mucosa of the Lateral Nasal Wall. f ... 21 

The Development of the Accessory Sinuses (Post-Embryonic). 22 

Rationale of the Physiological Development of the Accessory Sinuses. ... 24 

Physiology of the Accessory Sinuses. 25 

Role of the Sinuses During Respiration. 26 

Normal Mechanism of Drainage. 26 

Bacteriology of the Accessory Sinuses. 28 

Conclusions. 34 

General ^Etiology. y . 34 

Through Direct Invasion of the Healthy Sinus by Pathogenic Bacteria. 35 

Through Extension of Inflammation from Neighboring Parts. 39 

Tuberculosis, Syphilis, Neoplasms, and Latent Empyema. 39 

Through the Blood- and Lymph-channels. 41 

Through Traumatism. 41 

Through Foreign Bodies. 41 

Through Contamination by the Pus from an Overlying Sinus. Sinusitis and 

Sinuitide . 43 

Cause of Chronicity. 43 

Interference with Normal Drainage. 44 

Especial Virulence of the Infecting Micro-organism. 44 

Inflammatory Changes in the Mucous Membrane of the Sinus. 44 

Recurrence of the Attacks. 44 

Continuation of the Irritation. 45 

The Consistency of the Secretion. 45 

The Individual Susceptibility of the Patient. 45 

Secretion Flowing in from Another Sinus. 45 

Statistics. 46 

Pathological Changes in the Mucous Membrane of the Sinuses. 47 

The Microscopic Appearance of the Mucous Membrane in Acute Conditions. ... 48 

Hyperplastic Type. 49 

Differential Diagnosis. 50 

Ulcerative Type. 50 

Unusual Pathological Complications or Sequelae of Chronic Inflammation: 

New Formation and Ulceration of Bone, Caries, and Necrosis. 50 

New Bone Formation. 50 

Ulceration of the Bone. 51 

Caries and Necrosis. 51 


xi 









































xii 


CONTENTS. 


Dilatation of Sinus Wall by Internal Pressure of Secretion (Mucocele, 

Pyocele and Latent Empyema). 51 

Mucocele . 51 

Metamorphosis of the Secretion into a Cheesy Mass (Verkasung). 52 

Cholesteatoma Formation . 53 

Calcareous Formation . 53 

Carcinoma . 53 

Relative Importance of the Secretion in Chronic Empyema. 53 

Latent Empyema . 54 

Symptoms of Sinus Inflammation. 54 

Localized Headache. 54 

Cause . 55 

Lack of Constancy. 55 

Character . 56 

Periodicity . 57 

Variations in Intensity. 57 

Localization . 57 

Tenderness over the Sinuses. 59 

Purulent Secretion in the Nose. 60 

Cacosmia .'. 62 

Changes in the Nasal Mucosa Depending upon Sinus Disease. 62 

The Relation of Polyp Formation to Nasal Suppuration. 63 

Solitary Choanal Polyps. 66 

Other Changes in the Nasal Mucosa Depending upon Sinus Disease. 67 

Erysipelas . 67 

Changes in the Mucosa of the Upper Respiratory Tract. 68 

The Nasopharynx and Pharynx. 68 

Pharyngitis Sicca. 68 

Pharyngitis Lateralis . 68 

Laryngeal Affections . 68 

Pharyngeal Affections . 70 

Remote Local Symptoms. 70 

Dizziness and Vertigo. 70 

Psychical and Intellectual Disturbances. 71 

General Symptoms . 72 

Rheumatism and Rheumatic Pains. 72 

Fever. 72 

Circulatory Disturbances . 72 

Nervous Disturbances. 73 

Sexual Apparatus . 73 

Diagnosis : 

First Series . 73 

Second Series . 76 

Diagnosis by Means of (1) Transillumination, (2) Rontgen Ray, (3) Suction, 
and (4) Tuning-fork : 

Transillumination . 78 

Maxillary Sinus . 78 

Frontal Sinus . 80 

Ethmoid Cells . 80 

The Rontgen Ray. 81 

Frontal Sinus . 82 

Anterior Ethmoid Cells . 83 

Maxillary Sinus . 83 

Posterior Ethmoid and Sphenoid . 84 




















































CONTENTS 


xiii 


Bier’s Hyperaemia as Applied to the Nasal Sinuses. 84 

The Tuning-fork . gg 

Treatment . gg 

Acute . gg 

Negative Pressure . gg 

General Treatment . gg 

Local Treatment . qo 


Chronic Inflammation . 90 

Vaccine Therapy . 91 

Complications . 91 

Relation to the Orbital Cavity. 92 

Relation to the Optic Nerve . 92 

Relation to the Brain . 92 

Vessels and Nerves . 93 

Causes of Complications . 93 

Anatomical . 93 

Pathological . 94 

Manner of Occurrence . 94 

By Continuity—Dehiscence . 94 

By Contiguity . 94 

Mechanical Pressure . 96 

Pathological Conditions . 96 

Orbital Complications. 97 

Disturbances in Circulation . 97 

Intoxication . 97 

Purulent Inflammation . 97 

Orbital Symptoms . 98 

Those Caused by Inflammation. 98 

Those Caused by Pressure (Mechanical) . 99 

Those Caused by Toxins. 100 

Cerebral Symptoms .. .. 101 

Empyema of the Accessory Sinuses in Children. 101 

Treatment . 105 


PART II. 

MAXILLARY SINUS. 


Anatomy . 107 

Relative Importance of the Walls . 107 

Congenital Defects or Dehiscences. 109 

The Alveolar Boundary . 109 


The Relation of the Structures Forming the Lateral Wall of the Nose to 


the Base of the Sinus from Without Inward. Ill 

Normal Position of Ostium. 112 

Accessory Ostiums . 112 

Abnormalities and Anomalies of the Maxillary Sinus .. 112 

Anomalous Position of Walls. 114 

Formation of Partitions in the Maxillary Sinus . 117 

Relation of the Maxillary Sinus to the Lachrymo-nasal Canal . 119 

Blood Supply . 119 

Surgical Anatomy of the Lateral Wall of Nose in Reference to the Maxil¬ 
lary Sinus . 119 

Sounding the Maxillary Ostium . 120 

^Etiology . 121 

Idiopathic . 122 

Direct Extension from the Nasal Mucosa . 122 




















































xiv CONTENTS. 

Infectious Disease .•'. 122 

From the Alveolus . 123 

Through Contamination from Overlying Sinuses. 127 

Foreign Bodies . 128 

Traumatism—Direct and Indirect. 128 

Osteomyelitis, Syphilis, Tuberculosis, and Malignant Tumors. 129 

Chronic or Latent Empyema. 130 

Sequelae and Unusual Conditions Found in the Maxillary Sinus: 

Cysts . 130 

The Mucoid Cyst. 130 

Dentigerous Cysts . 131 

Caseous Metamorphosis (Verkasung). 134 

Mucous Polyps . 135 

Membranous Formation in the Maxillary Sinus. 136 

Stone Formation in the Maxillary Sinus. 136 

Mucocele of Maxillary Sinus. 136 

Cholesteatoma Formation . 136 

Diagnosis . 137 

Closed Empyema of Maxillary Sinus. 140 

Adjuncts to Diagnosis : 


Transillumination . 140 

Mechanism of Transillumination. 141 

Actual Cause of Shadow Formation. 141 

Value as to Reliability. 141 

Rontgen Ray . 142 

Suction or Negative Pressure. 142 

Symptoms . 143 

Nasal Symptoms . 144 

General Disturbances . 145 

Complications . 146 

Chronic Empyema . 147 

Pain . 147 

Secretion . 149 

Constancy of the Flow of Pus. 150 

Periodicity of Emptying. 150 

Changes in Consistency. 150 

Nasopharynx and Larynx. 151 

Disturbances in Olfaction. 151 

Nervous Manifestations . 152 

Complications : 

Caries of the Osseous Walls of the Antrum, with Rupture into the Neighboring 

Parts, with Abscess Formation. 153 

Dilatation of the Antrum. 153 

Empyema Complicated or Caused by Cyst Formation. 154 

Differential Diagnosis . 154 

Prognosis and Indications for Treatment. 155 

When Shall We Operate. 156 

Treatment : 


Technique of Sounding and Catheterizing the Maxillary Sinus. 167 

Relation of the Ostium to the Internal Wall of the Maxillary Sinus. 167 

Technique of Needle Puncture with Lavage. 163 

Conservative Treatment . 171 

After-treatment . 180 

After-treatment . 181 

Dahmer’s Method. 183 

After-treatment . 185 





















































CONTENTS 


XV 


Canfield’s Operation. Ig 5 

After-treatment . 186 

Preturbinal Method. 187 

After-treatment . 188 

Radical Operative Treatment. 19 Q 

Caldwell-Luc Method . 190 

Technique of the Operation. 190 

Operation under Local Anaesthesia. 194 

After-treatment . 195 

Denker’s Method . 196 

Modification of the Caldwell-Luc Method. 198 

Results and Untoward Sequelae of the Radical Operation. 199 

Immediate and Ultimate Effects of the Radical Operation on the Maxillary 

Sinus . 200 


PART III. 

FRONTAL SINUS. 

Anatomy . 201 

Thickness of Walls. 203 

Dehiscence of the Walls. 204 

Interior of Sinus. 204 

Relation of the Hiatus Semilunaris to the Frontal Sinus. 208 

Relation of the Frontal Sinus to the Ethmoid Labyrinth. 209 

Bulla Frontalis . 212 

Mucosa of Sinus, Blood Supply. 212 

Sounding the Frontal Sinus. 212 

Technique of Sounding the Frontal Sinus. 213 

Natural Difficulties Encountered in Sounding the Frontal Sinus. 214 

Acute Inflammation: Aetiology. 216 

Pathology .... 218 

Acute Catarrhal . 218 

Microscopical . 218 

Acute Purulent. 219 

Microscopical . 219 

Diagnosis. 219 

Symptoms—Acute: 

Pain and Headache. 221 

Tenderness on Pressure and Percussion. 223 

Secretion . 224 

Locality of Secretion. 224 

Appearances of the Nose. 224 

Internal ... 224 

External . 225 

External Appearance of the Sinus. 225 

Disturbances in Olfaction. 225 

General Disturbances . 226 

Prognosis . 226 

Complications . 227 

Periostitis and Ostitis. 227 

Caries and Necrosis. 227 

Osteomyelitis . 228 

Circumscribed .. .. 228 

Diffuse .. 228 


















































xvi CONTENTS. 

Pathology . 2 ^ 

Symptoms . 2 ^ 

Orbital Complications . 229 

Intracranial Complications . 230 

Treatment . 23 ^ 

Technique of Infraction of the Middle Turbinate. 233 

Technique of Resection of Anterior Third of Middle Turbinate. 235 

Complications . 23 ^ 

Chronic Inflammation: ^Etiology.. 237 

Retention of Secretion within the Sinus. 238 

Pathology .. 23 ^ 

Catarrhal or Fibrous . 239 

Purulent . 23 ^ 

Microscopical . 240 

Symptoms . 2 ^1 

Pain . 241 

Location . 242 

Constancy . 242 

Tenderness on Pressure. 242 

CEdema of Upper Eyelid..*. 243 

Secretion . 243 

Place of Appearance of Secretion. 244 

Disturbances in Olfaction.• • 244 

Appearance of the Nose. 245 

Rhinoscopy . 245 

Appearances of the Throat. 240 

Dizziness and Vertigo. 240 

Diagnosis . 247 

External Symptoms . 250 

Dilatation of Anterior Wall and Fistula Formation. 251 

Cause of the Fistula Formation. 251 

Adjuncts to Diagnosis: 

Transillumination . 252 

Rontgen Ray. 253 

Differential Diagnosis . 253 

Prognosis : 

Tuberculosis . 255 

Syphilis . 255 

Chronic Complications . 250 

Possible Paths of Infection. 250 

Oculo-orbital Complications . 259 

Intracranial Complications . 200 

Treatment . 205 

Resection of the Anterior Portion of the Middle Turbinate. 200 

Resection of the Uncinate Process. 208 

Ingals’s Intranasal Operation . 209 

Halle’s Intranasal Operation . 271 

Halle’s Improved Method . 273 

Good’s Intranasal Operation. 274 

Thomson’s Modification of Good’s Method. 275 

Comparative Value of the Intranasal Operation. 277 

Indications for External Radical Operation . 278 

Evolution of the External Operation on Frontal Sinus. 278 



























































CONTENTS. xvii 

Exploratory or Conservative Opening... 277 

Knapp’s Operation . 285 

Radical or Modified Killian Operation. 280 

Osteoplastic Resection. 293 

Lothrop’s Operation..294 

Beck’s Method of Osteoplastic Resection. 295 

Watson Williams Osteoplastic Method. 296 

Citelli’s Method . 296 

Comparison of Methods. 297 

The Ogston-Luc Operation. 297 

Kuhnt’s Method for Obliterating the Sinus. 297 

Killian’s Method . 298 

Untoward Results Following the Killian Radical Operation. 299 

The Ultimate and Permanent Condition of the Operated Frontal Sinus . 302 

PART IV. 

ETHMOID LABYRINTH. 

Anatomy . 305 

Lateral Nasal Aspect . 305 

Lamella of Uncinate Process .•. 307 

Lamella of the Bulla . 308 

Lamella of Middle Turbinate. 308 

Lamella of Superior Turbinate. 309 

Relation of Anterior Ethmoid Labyrinth to Frontal Sinus. 313 

Anomalies of Ethmoid Labyrinth. 313 

Blood Supply . 322 

Venous Anastomoses . 322 

Relation of Posterior Ethmoidal Cells to Optic Nerve. 323 

Physiology of the Ethmoid. 324 

^Etiology and Pathology. 325 

Acute Catarrhal Inflammation. 326 

Acute Purulent Inflammation. 326 

Symptoms . 326 

Diagnosis and Prognosis. 327 

Treatment . 327 

Acute Suppurative Ethmoiditis. 328 

Chronic Inflammation of the Ethmoid Labyrinth. 328 

^Etiology . 328 

Pathology . 328 

Microscopic Examination. 329 

Symptoms . 330 

Diagnosis . 331 

Treatment . 332 

Sluder’s Method..■'• • •.-.. 333 

Chronic Suppurative Inflammation (Empyema). 335 

etiology .:. 335 

Pathology . 336 

Symptoms . 337 

Secretion . 337 

Olfactory Disturbances. 337 

Rliinoscopic Examination . 338 

Diagnosis . 338 

Transillumination . 339 

Differential Diagnosis . 340 

Closed-in or Latent Empyema. 340 






















































XVIU 


CONTENTS. 


Chronic Hyperplastic Inflammation with Suppuration . 344 

Complications . 345 

Orbital: Acute and Chronic Rupture into the Bulbar Cavity. 346 

Inflammation of the Lachrymal Duct. 348 

Cerebral: Intracranial Complications . 348 

Prognosis . 348 

Conservative Treatment . 349 

Treatment by Vaccination . . . .. 350 

Intranasal Method . 350 

Mosher’s Method of Complete Exenteration of the Ethmoid Capsule. 353 

Method of Luc . 353 

Sluder’s Method . 354 

Hajek’s Method for Removing Posterior Ethmoid Cells . 355 

Slight Complications Sometimes Following Intranasal Operation. 355 

Emphysema of the Upper Eyelids on Blowing the Nose . 356 

External Operation . 356 

Method of Guisez . 357 

Untoward Results Following the External Operation . 360 

Blindness... 360 

Diagnostic Indications . 361 

Ultimate Results from Operative Procedures . 367 

PART V. 

SPHENOID SINUS. 

Anatomy . 369 

Peculiar Anomalies and Formations.. 375 

Mucosa of Sphenoid ... 377 

Acute Inflammation: 

^Etiology . 378 

Pathology . 379 

Microscopic Histo-patliology . 381 

Symptoms . 379 

Diagnosis . 379 

Treatment . 380 

Chronic Inflammation : 

^Etiology . 380 

Pathology . 380 

Microscopic Histo-pathology . 381 

Symptoms . 381 

Headache . 383 

Mental Symptoms . 384 

Secretion . 384 

Ocular Symptoms . 385 

Objective Symptoms ... 386 

Diagnosis . 387 

Mucocele . 390 

Sounding the Sphenoid Sinus. 390 

Technique of Sounding. 39 \ 

Grayson’s Operation . 393 

Differential Diagnosis . 394 

Empyema of a Sphenoid-ethmoidal Cell. 397 

Empyema of the Posterior Half of a Double Maxillary Sinus. 397 

















































CONTENTS. 


XIX 


Prognosis . 397 

Complications . 398 

Thrombosis of Cavernous Sinus . 400 

Symptoms . 401 

Ophthalmic Manifestations . 401 

Treatment . 402 

Technique of Catheterization and Irrigation . 403 

Technique of Enlarging the Normal Ostium . 404 

Indications for the Radical Operation . 406 

Radical Operation of Sphenoid . 408 

After-treatment . 412 

Halle’s Operation . 413 

Ultimate Condition of the Operated Sinus. 413 

Maxillary Route . 414 

Jansen’s Method . 414 

PART VI. 

COMBINED EMPYEMA OR MULTIPLE SINUSITIS. PANSINUSITIS. 

Combined Empyema or Multiple Sinusitis . 417 

Treatment . 418 

Pansinusitis . 421 























ILLUSTRATIONS 

FIG. PAGE 

1. Lateral wall of nose showing relation of pendulous portion to intercranial. ... 1 

2. Direction and extent of light rays in examination of the anterior portion of 

the nares . 1 

3. Killian’s nasal speculum. 2 

4. Lateral wall of nose with mucosa intact. 3 

5. Ethmoid, superior maxilla, and palate bone..., . 4 

6. Scheme showing articulation of inferior turbinate. 5 

7. (a, 6) Right inferior turbinate. 6 

8. Superior maxilla lachrymal, inferior turbinate, and palate hone in normal 

position . 6 

9. Ethmoid, superior maxilla, and palate hone in normal position. 7 

10. Lateral wall of nose with a portion of middle and inferior turbinates removed. . 8 

11. Lateral wall of nose showing processus uncinatus and pars membranacea. 9 

12. Lateral wall of nose showing accessory ostium. 10 

13. Ethmoid, superior maxilla, and palate bone in normal position. 11 

14. Relation of ethmoid capsule to surrounding structures. 13 

15. Cross section behind uncinate process. 14 

16. Diagrammatic illustration of the ethmoid capsule. 14 

17. Section through ethmoid capsule posterior to the hiatus semilunaris. 15 

18. Frontal, ethmoidal, and superior maxilla disarticulated. 15 

19. Frontal, lachrymal, ethmoidal, and superior maxillary, in normal position.... 16 

20. Lateral wall of the nose with ethmoid labyrinth opened. 18 

21. Relation of sinuses and hiatus semilunaris to lateral wall of the nose. 18 

22. Transverse section through the middle of the uncinate process and bulla. 19 

23-24. Schematic illustration of the two formations of the hiatus semilunaris. 20 

25. Direct connection between the frontal and maxillary sinuses. 20 

26. Lateral wall of the nose with anterior half of the middle turbinate removed. . 21 

27. Section through head of foetus at birth.. 22 

28-29. Superior maxilla of foetus at birth. 23 

29a. Specimen from a child, eight years, eight months, and one day old. 24 

30. Distribution of the three branches of the trigeminus nerve. 56 

31. Schematic illustration of pain areas due to sinus disease. 58 

32. Method of holding the lamp against the inferior wall of the frontal sinus 

for transilluminating . 79 

33. Relation of the optic nerves to the posterior ethmoid cells. 91 

34. Relations of frontal, sphenoidal and ethmoidal sinuses to the brain. 91 

35. The veins of the orbital, ethmoidal and sphenoidal regions from above downward 92 
36-37. Showing extent and shape of maxillary sinus in the superior maxillary.. .. 104 

38. Various structures entering into the base of the maxillary sinus. 104 

39. Section through anterior portion of the antrum looking forward. 105 

40. Section through the anterior third of the antrum. 105 

41. Nasal packing forceps . 105 

42. Relation of the roots of the teeth to the floor of the maxillary sinus. 110 

43. Thick cancellated bone intervening between the teeth and the antral floor...... Ill 

44. Thick cancellated bone between the apex of the tooth root and the sinus floor.. Ill 

*45. Roots of teeth projecting into the maxillary sinus cavity. Ill 


xxi 











































ILLUSTRATIONS. 


xxii 

46. Lateral view of tooth root projecting into the maxillary sinus. m 

111 

47. View of maxillary sinus from without. 111 

48. Ostium divided by ridge of mucous membrane. m 

49. Showing situation of accessory ostium in relation to that of the normal ostium 112 

50. Several accessory ostiums. 

51. Excessive overdevelopment of maxillary sinuses on left with formation of orbital 

fossa . 

52. Excessive development of sinus due to over-reabsorption of cancellous tissue. . . 113 

53. Marked asymmetry of maxillary sinuses. 113 

54. Reabsorption of bone into the hard palate. 

55. Underdevelopment of maxillary sinuses with compact alveolar processes. 114 

56. Narrowing of the antrum due to sinking in of the anterior wall. 116 

57. Narrowing of the antrum due to bulging outward of lateral nasal wall. 116 

58. Sinking out of lateral nasal wall. 116 

59. Complete septum dividing antrum into an anterior and posterior compartment 117 

60. Ostiums of a double maxillary sinus. 118 

61. Maxillary ethmoid cell at posterior superior angle of antrum. 120 

61a. Relation of the lachrymal duct to the maxillary sinus. 120 

62. Unusually large bulla ethmoidalis. 120 

63. Upward displacement of bulla with enlargement of the hiatus semilunaris. . . 120 

64. Cross section through both maxillary sinuses. 131 

65. Large glandular mucoid cyst almost filling antrum of left side. 132 

66. Dentigerous or true bone cyst of an antrum on right side. 132 

67. (a, b, c, cl) Section through a tooth and root cysts. 133 

68. Position and bending of sound necessary in attempting to sound the maxillary 

sinus . 166 

69. Position of needle when introduced in relation to inferior turbinate, maxillary 

sinus and nasal septum. 163 

69a. Lichtwitz needle for puncture of the maxillary sinus. 169 

70. Position of needle in puncture of the maxillary antrum. 168 

71. Position of the hands in introducing the Lichtwitz needle into the right maxil¬ 

lary sinus. 170 

72. Antral trocar with cannula. 170 

73. Fletcher’s needle for puncture of the maxillary sinus. 174 

74. Guarded Hartmann borer. 178 

75. Enlarging the opening in the Cowper operation through the alveolar process. . . 179 

76. Prothese for closing opening in the alveolus after the Cowper operation. 179 

77. Wilhelmski’s antral trocar. 181 

78. Wagener’s antrum punch. 182 

79. Freeman’s syringe . 182 

80. Privat’s subperiosteal syringe for local anaesthesia. 183 

81. Dahmer’s method. First step . 184 

82. Dahmer’s method. Second step . 184 

83. Dahmer’s method. Third step . 184 

84. Right-angle knife . 184 

85. Dahmer’s method. Fourth step . 184 

86. Dahmer’s method. Fifth step . 184 

87. Dahmer’s method. Sixth step . 185 

88. Dahmer’s method. Seventh step . 185 

88a. Initial incision along lateral wall of pyriform opening. 185 

886. Submucous resection of inferior turbinate. Anterior view. 185 












































ILLUSTRATIONS. xxiii 

88c. Showing how antrum is exposed fully to view. Side view.. .. 186 

89. The pre-turbinal method. First step . 186 

90. The pre-turbinal method. Second step . 186 

91. The pre-turbinal method. Third step . 188 

91a. Anterior crest of bony wall exposed. 188 

92. Pre-turbinal method. Fourth step . 188 

93. Pre-turbinal method. Fifth step . 188 

94. Pre-turbinal method. Sixth step . 189 

95. Size of opening into antrum at conclusion of operation. 189 

96. Hajek’s retractor for holding up the lip in the external operation on the maxil¬ 

lary sinus . 190 

97. The mouth in position for the Caldwell-Luc operation on the maxillary sinus 190 

98. Incision made through soft parts and periosteum elevated, exposing underlying 

bone of the anterior wall. 191 

99. Anterior wall removed.191 

100. Mucosa of maxillary sinus removed. 192 

101. The bony wall separating the sinus from the nose removed. 192 

102. The mucosa is incised and the flap turned into the antrum. 193 

103. Caldwell-Luc operation completed. 196 

404. Denker operation complete. 196 

104a. Denker operation. Incision through mucosa and periosteum. 196 

1046. Denker operation. After elevation of mucosa. 196 

104c. Denker operation. Elevating mucosa . 196 

104d. Denker operation. Superior cut . 196 

104e. Denker operation. Inferior cut . 196 

104/. Denker operation. Removing . 196 

104g. Denker operation. Bony ridge ./. 196 

104/i. Denker operation. Removing portion of nasal wall. 196 

104i. Denker operation. Probe in nose showing mucosa. 196 

104/. Denker operation. After mucosa has been resected. 196 

M05. Completed Denker and Caldwell-Luc operations on skull. 198 

106. Hajek-Claus bone forceps. 198 

107. Lateral view of a medium-sized frontal sinus. 201 

108. Diagrammatic representation of the form and extent of the frontal sinus. 202 

109. Extreme lateral extension of the frontal sinus into the malar bone. 202 

110. Extreme superior extension of the right frontal sinus. 202 

111. Extension of frontal sinus posteriorly into lesser wings of sphenoid. 202 

112. Right and left frontal sinuses of the same size and conformation. 203 

113. Asymmetry of frontal sinuses. 203 

114. Absence of left frontal sinus. 203 

115. Irregularity of frontal sinuses. 203 

116. Extreme lateral extension of frontal sinus. 205 

117. Frontal sinus sending projections high up into the frontal bone. 205 

118. Left frontal sinus opened from above. 206 

119. Direct communication of the frontal sinus with an anterior ethmoid cell. 207 

120. Formation of ductus nasofrontalis. 207 

121. Lateral wall of nose with marked nasofrontal duct. 208 

122. Lateral view of a medium-sized frontal sinus. 209 

123. Lateral wall of nose with anterior portion of middle turbinate removed. 210 

124. Frontal bone and ethmoid capsule disarticulated. 210 

125. Frontal bone and ethmoid capsule in place. 211 





















































XXIV 


ILLUSTRATIONS. 


125a. Prolongation of frontal sinus into crista galli. 211 

126. Sound bent for frontal sinus..,/. 213 

127. Sounding the frontal sinus after removal of the anterior portion of the middle 

turbinate . 214 


128. Measuring the distance the sound has penetrated against the side of the 


patient’s nose . 215 

129. Anterior ethmoid cell situated beneath the uncinate process. 216 

130. Extension of entire ethmoidal labyrinth. 216 

131. Lateral wall of nose with middle turbinate removed. 217 

132. External table of skull removed, showing the canals of Breschet. 229 

133. Thompson’s nasal scissors..... 233 


134. Severing the middle turbinate at its anterior attachment to the lateral nasal 


wall . 

135. Infracting the middle turbinate with a blunt elevator. 

136. Position of snare in removing the anterior portion of the middle turbinate. . . . 

137. Hartmann’s cutting forceps. 

138. Cannula for irrigation of the frontal sinus. 

139. Position of the hands in irrigating the frontal sinus. 

140. Venous anastomoses of the nose and orbit (colored). 

141. Enormous mucocele of the frontal sinus. 

142. Burrell’s nasal shave. 

143. Removing the uncinate process with the nasal shave. 

144. Using Lange’s forceps to enlarge the nasofrontal passages. 

145. Operation completed .. 

146. Ingals’s operation . 

147. Ingals’s gold tube for intranasal insertion into the frontal sinus. 

148. Halle’s operation ... 

148a. Halle’s operation completed. 

149. Halle’s method. A. Preliminary incision. B. Flap turned back. C. Opening 

sinus with pear-shaped breve. D. Floor of sinus removed. E. Cutting 
interior of sinus. F. Flap replaced. 

150. Rasp in place for enlarging the frontal ostium. 

150a. Sullivan’s frontal sinus rasps. 

150&. Incision for exploratory opening of frontal sinus. 

150c. Incision through periosteum and opening in frontal sinus. 

151. Line and extent of incision in the Killian operation on the frontal sinus. 

152. Two periosteal incisions. 

153. Killian’s V-shaped chisel. 

154. Illustrating grooves made in the ascending process of the superior maxillary 

and below lachrymal bone in order to resect this portion. 

155. Killian operation completed. 

156. Knapp’s incision .*.. 

157. First step . 

158. Second step . 

159. Third step . 

160. Fourth step . 

161. Alexander’s hollow chisel. 

162. Bone-cutting forceps for removing the anterior wall of the frontal sinus.. 

163. Fifth step . 

164. Sixth step. 

165. Seventh step . 


234 

234 

234 

236 

248 

249 

258 

259 
268 
268 
268 
270 

270 

271 

272 
272 


274 

275 

276 
280 
280 
282 
282 

283 

284 

284 

285 
287 

287 

288 
288 
289 

289 

290 
290 
290 
















































ILLUSTRATIONS. xxv 

166. Eighth step .•. 290 

167. Ninth step .•. 291 

168. Tenth step .. 291 

169a. Eleventh step . 292 

1696. Twelfth step . 292 

170. Osteoplastic resection of the anterior wall of the frontal sinus. 294 

170a. Lothrop’s operation, incision . .. 294 

1706. Lothrop’s operation, external opening into sinus. 294 

1 / 0c. Lothrop s operation, probe passed through sinus emerging from nose. 294 

170d. Lothrop’s operation, aspect of lateral wall. 294 

170e. Lothrop’s operation, aspect of septum. 294 

171. Beck’s method of osteoplastic resection of the frontal sinus. 296 

172 Schematic reproduction of the construction of the ethmoid capsule. 306 

173. Small bulla ethmoidalis. 307 

174. Unusually large ethmoidalis. 307 

175. Formation of ductus nasofrontalis. 308 

176. Cross section through the ethmoid close to the cribiform plate. 309 

177. Entire ethmoid capsule is composed of three cells. 310 

178. Extension of entire ethmoidal labyrinth. 310 

179. Ethmoid labyrinth opened from the orbit. 311 

180. Another labyrinth opened from the orbit. 311 

181. Diagrammatic representation of infundibular cells. 312 

182. Section through ethmoid labyrinth. 312 

183. Frontal sinus and hiatus semilunaris forming a straight passage. 313 

184. Frontal bulla formed by the upward and forward displacement of the lamella 

of bulla ethmoidalis onto the posterior wall of the frontal sinus. 314 

185. Anomalous situation of the uncinate process... 314 

186. Anterior ethmoid cell situated beneath the uncinate process. 315 

187. Frontal bulla formed by encroaching of an infundibular cell into the frontal 

sinus . 315 

188. Downward displacement of bulla with obliteration of the hiatus semilunaris. . 316 

189. Upward displacement of bulla with enlargement of the hiatus semilunaris. ... 316 

190. Formation of a frontal bulla through the upward extension of the lamella of 

the uncinate process. 317 

191. Backward displacement of the ethmoidal bulla with the formation of a pre- 

ethmoidal recess . 317 

192. Lamella of middle turbinate displaced forward. 318 

193. Showing reduced size of ethmoid labyrinth in the absence of the frontal and 

and sphenoidal sinuses. 318 

194. Fronto-ethmoidal cell extending almost the width of the orbit. Cell in crista 

galli . 319 

195. Fronto- or orbito-ethmoid cell. 320 

196. Anomalously situated ethmoid cell. 321 

197. Lateral wall of nose with spheno-ethmoidal cell showing intimate relation of 

optic nerve . 323 

198. Normal relation of optic nerves to sphenoid sinus and posterior ethmoid cells 324 

199. Direction of air currents through the nose. 325 

200. Lange’s frontal sinus and ethmoid punch. 332 

200a. Sluder’s method, knife incision . 334 

2006. Sluder’s method, removal of turbinate with snare. 334 

201. Ballenger’s ethmoid knives. 334 













































xx vi ILLUSTRATIONS. 

202. Exenterating ethmoid capsule en masse with the Ballenger right-angle knife. . 335 

203. Cell in middle turbinate filled with pus. 342 

204. Middle turbinate and superior lying cells filled with pus. 342 

205. Bulla filled with pus.. 342 

206. Marked exophthalmos due to rupture of an ethmoidal empyema through the 

lamina papyracea into the orbit. 347 

207. Hajek’s instruments for removing the ethmoid cells. 350 

208. Opening the ethmoidal bulla with Hajek’s hook. 351 

208a. Removal of the bulla with the Griinwald conchotome. 351 

209. Mosher’s operation. A. First step: curette in place. B. Third step: middle 

turbinate borne through. C. Fourth step: curetting away processus unci- 
nateus. D. Ethmoid cells removed with curette underneath middle turbi¬ 
nate. E. Middle turbinate being removed with scissors. F. Completed.... 353 

210. Seizing and twisting the middle turbinate from its anterior attachment. 354 

210a. Sluder’s method, superior knife incision. 354 

2106. Sluder’s method, inferior knife incision. 354 

211. The hook behind the posterior portion of the middle turbinate in position for 

severing the turbinate from its attachment. 354 

211c. Sluder’s method, removing turbinate with snare. 355 

21 Id. Sluder’s method, removing debris with forceps. 355 

212. The ethmoid hook in position for reducing the superior turbinate to fragments 354 

213. Finishing the stroke... 354 

214. Removing the fragments and shreds. 356 

215. Position and length of incision for external radical exenteration of the anterior 

and posterior ethmoid cells. 357 

216. Periosteum retracted and bone bared. 357 

217. Point of election for opening the ethmoid labyrinth. 358 

218. The operation completed.;. 358 

219. Sphenoid bone and ethmoid capsule disarticulated. 369 

220. Sphenoid bone and ethmoid capsule in position. 370 

221. Section through both sphenoid sinuses. . . 370 

222 . Sphenoid sinus enlarged anteriorly. 37 \ 

223. Section behind the uncinate processes. 372 

224. Position of sphenoidal ostium. 372 

225 Varied conformations of superior walls of the sphenoid sinus. 373 

226. Entire sphenoid sinus surrounded by cancellated bone tissue. 374 

227. Relation of internal carotid arteries to posterior sphenoidal wall. 375 

228. Reabsorption of sphenoid sinus into the lesser wings of sphenoid bone. 375 

229. Reabsorption into palatine fossa. 375 

230. Reabsorption into pterygoid process. 377 

231. Splieno-ethmoidal cell formation. 377 

232. Sounding the sphenoid sinus. 392 

233. Jacob’s method of sounding and catheterizing the sphenoid sinus. 393 

233a. Grayson’s operation . . . t . 393 

234. Position of the hands of patient and surgeon in irrigating the sphenoid sinus 402 

235. Farad’s bone-cutting forceps for enlarging the sphenoidal ostium. 404 

236. Enlarging the natural ostium of the sphenoid sinus without removal of middle 

or superior turbinate... 49g 

237. Severing the middle turbinate in the centre prior to the removal of the poste¬ 

rior half . 

238. Radical intranasal operation on sphenoid. ^qq 










































ILLUSTRATIONS. 


xxvii 

239. Radical intranasal operation on sphenoid. 408 

240. Radical intranasal operation on sphenoid. 409 

241. Radical intranasal operation on sphenoid. 409 

242. Radical intranasal operation on sphenoid. 411 

243. Evulsor for sphenoid. 411 

244. Hajek’s modified sphenoid forceps. 412 

245. Radical intranasal operation on sphenoid. 414 

246. Relation of an unusually large sphenoid sinus to the maxillary antrum. 415 

247. Relation of a small sphenoid sinus to the maxillary antrum. 415 

COLORED PLATES. 

A. Lateral wall of nose with mucosa intact. B. Lateral wall of nose with 
mucosa removed. C. Lateral wall of nose with inner wall of ethmoid cap¬ 
sule removed. D. Lateral wall of nose. All structures being removed to 
orbital plate . Frontispiece 

1. A. Blood supply of lateral nasal wall. B. Nerve supply of lateral nasal wall. .. 22 

2 . A. Normal mucosa of ethmoid. B. Acute inflammation. C. Chronic inflam¬ 

mation . 50 

2 a. Large polyp extending into pharynx. Uvula retracted. 66 

26. View through the nasophravngoscope of the sphenoidal region. 76 

3. Transillumination of maxillary sinus. Right side normal. Left side diseased.. 78 

4. Rontgen ray photograph showing position of sphenoid sinuses. . . .. 82 

5. Rontgen ray photograph showing lateral position of sphenoid sinus. 84 

















I 



























































































THE ACCESSORY SINUSES 
OF THE NOSE 


PART I. 


GENERAL CONSIDERATIONS. 


EXAMINATION OF THE NOSE FOR SINUS DISEASE. 


The nose may be likened nnto a square box opened behind by 
a large aperture in the posterior wall but practically closed in 
front except for a small opening at the inferior margin. This 
anterior opening is not really in the nose itself but rather in a 
triangular addition which closes it in from the front. (Fig. 1.) 

It will be noted that every structure of importance as far as 
the sinuses are concerned lies behind the line a-b. Therefore, the 



Fig. 2. —Direction and extent of light 
rays in examination of the anterior portion 
of the nares. 


Fig. 1.—Lateral wall of nose showing relation 
of pendulous portion to intercranial. 


triangular portion a-b, b-c, c-a, corresponding to the external nose 
must be eliminated when studying the accessory cavities. We 
must also bear in mind that the rays of light thrown in by the 
mirror will illuminate but a small portion of the entire area lying 
posterior to line a-b on account of the narrow aperture (nares) 
through which they must pass; therefore, it will be necessary to 
turn the head of the patient in a number of positions before every 
part can be seen by anterior rhinoscopy. Examination of the 
nose with the light directed in this position will bring out clearly 

l 1 









2 THE ACCESSORY SINUSES OF THE NOSE. 

the anterior end and inferior surface of the middle turbinate. 
(Fig. 2.) . 

The relative position of this structure is misleading, as it 
appears as though the cribriform plate must be hut a very short 
distance above. As a matter of fact, the inferior margin of the 
middle turbinate corresponds approximately to the half-way line 
between the cribriform plate and floor of the nose (see Frontis¬ 
piece). In other words, the distance between the cribriform plate 
and the inferior margin of the middle turbinate is as far as the 
distance between the floor of the nose and the inferior margin of 
the middle turbinate. The middle turbinate usually lies so close 
to the nasal wall that the uncinate process and bulla ethmoidalis 
are entirely hidden from view. As it is absolutely necessary to 
obtain some knowledge of the underlying conditions when a sinus 



disease is suspected, we must employ some means whereby these 
parts may be inspected. This is best accomplished by the Killian 
method of median rhinoscopy. 1 A Killian speculum (Fig. 3) is 
introduced so that the blades come between the bulla and the 
middle turbinate. By gently but firmly springing the branches 
apart, the underlying parts (processus uncinatus, hiatus semi¬ 
lunaris and bulla) are brought into view. If pus is present in 
any of the sinuses of the first series (those emptying into the 
hiatus) it will he disclosed by this procedure. 

It frequently occurs while performing median rhinoscopy, a sudden snap is 
heard and the middle turbinate is fractured at its base or juncture with the ethmoid 
capsule. Absolutely no harm can result from this, and indeed it is rather an 
advantage, especially if sinus trouble is present, as it allows a much better drain¬ 
age from the hiatus. Kirstein, 2 Uffenorde 3 and the author frequently perform this 
intentionally as a therapeutic measure in acute sinusitis. 

I. Killian: Ueber rhinoscopia media. Munch med. Wochenscrift, S. 768, 1896. 

2. Kirstein: Rhinoscopia nach Killian. Berl. lary. Ges., Bd. 7, S. 13; Bd. 8, S. 9. 3. Uffen¬ 

orde; Erkrankungen des Siebbeins, S. 150, 1907, Jena. 



GENERAL CONSIDERATIONS. 


3 


The range of vision by anterior rhinoscopy as far as the depth 
of the nose is concerned can hardly be more than two-thirds of 
the inferior margin of the middle turbinate, except in atrophic 
noses, when the anterior wall of the sphenoid and occasionally the 
ostium may be observed. The long Killian speculum placed with 
the branches between the middle turbinate and septum gives one a 
slit-like view in the depths, but for general purposes is unsatisfac¬ 
tory, at least as far as the author is concerned. It is better to rely 
upon the nasopharyngoscope or posterior rhinoscopy for informa¬ 
tion regarding the condition of the sinuses of the second series 
(posterior ethmoid and sphenoid). 

ANATOMY OF THE LATERAL WALL OF THE NOSE. 

For rhinological purposes this wall may be divided into three 
portions. 1. The inferior turbinal portion. 2. The middle nasal 
passage. 3. The ethmoidal portion. (Fig. 4.) 


Frontal sinus 


Olfactory 
fissure 
Superior 
turbinate 
Agger nasi 
Superior na¬ 
sal passage 
Middle 
turbinate 
Middle nasal 
passage 

Inferior 

turbinate 

Inferior na¬ 
sal passage 
Inferior 
nasal spine 


Fig. 4. —Lateral wall of nose with mucosa intact. 



1. The inferior turbinal portion extends from the superior 
insertion of the inferior turbinate in the maxillary bone to the 
floor of the nose, thereby including the turbinate in its boundaries. 

2. The middle nasal passage includes that portion of the 
lateral nasal wall lying above the inferior turbinate and below the 
ethmoidal bulla and posterior attachment of the middle turbinate. 











4 


THE ACCESSORY SINUSES OF THE NOSE. 


It is, therefore, bounded above, anteriorly, by the bulla, above 
posteriorly by the attachment of the middle turbinate, externally 
by the uncinate process, hiatus semilunaris and pars membran- 
acea, below by attachment of inferior turbinate, and internally, 
partially by the middle turbinate and partially by the septum. 
The ostiums of the sinuses of the first series empty into this 
passage (Frontispiece). 

3. The ethmoidal portion of the lateral wall of the nose in¬ 
cludes all of those structures situated above the inferior margin 
of the middle turbinate, i.e., bulla ethmoidalis, middle turbinate, 
ethmoid capsule including superior turbinate (Frontispiece). 

Basic Structure of the Lateral Nasal Wall. 

Two structures form the principal component parts: 1. Supe¬ 
rior maxillary bone (inferior portion). 2. Ethmoidal capsule 
(superior portion). (Fig. 5.) 



-Ethmoid 


Palate bone 


Fig. 5. —Ethmoid, superior maxilla and palate bone. 


The entire structure is completed by the addition of the palate 
and inferior turbinate and lachrymal bones. The internal as¬ 
pect of the superior maxillary bone or inferior portion presents 
conspicuously a large opening (hiatus maxillaris) leading into a 




GENERAL CONSIDERATIONS. 


5 


crater-like cavity which is partially closed in by the overlapping 
edges of bone (maxillary sinus). In the recent state this sinus 
is entirely closed in, with the exception of one (rarely more) small 
ostium, hidden by the lip-like projection of the uncinate process. 
How, then, is this hiatus maxillaris walled up and what structures 
enter into the formation of this partition between the maxillary 
sinus and the nasal cavity? 


a b 



Fig. 6.—Scheme showing articulation of inferior turbinate. 

We note that the opening is not round but rather takes on the 
character of a broad V at its inferior margin (see Fig. 5). 
This portion is closed in by serving as a place of articulation for 
the maxillary process of the inferior turbinate in the following 
manner. The inferior turbinate does not articulate with the 
lateral nasal wall as a pendulous body (Fig. 6a), but by a com¬ 
paratively broad base which forms a distinct portion of that wall 
(Fig. 6b, 7b.) 


a b 



Fig. 7, a, b .—Right inferior turbinate. a, internal surface. b, external surface showing maxillary- 
process which contributes toward formation of internal antral wall. 


This base fits snugly into the V shaped edge of the max¬ 
illary hiatus and with the latter completely encloses the lower 
fourth of the maxillary antrum. (Fig. 8.) The wall of bone at 
the floor of the nose is comparatively thick, gradually becoming 
thinner until it articulates with the maxillary process. The max¬ 
illary process, however, is much thinner,, forming the thinnest 
portion of the lateral wall below the inferior turbinate; therefore, 







6 


THE ACCESSORY SINUSES OF THE NOSE. 


it is plain to see why this part is chosen as the point of election 
for exploratory needle puncture of the maxillary sinus. 

Here we have the lower fourth of the partition completed, but 
no more. What structures then enter into the formation of the 
remaining three quarters? A glance at Fig. 9 and Fig. 10 will 
at once show how largely the ethmoid enters into formation of the 
lateral wall of the nose. If one draws a straight line from the 
floor of the nose to the cribriform plate it will be seen that the 
ethmoid capsule occupies practically one-half of the entire dis¬ 
tance. In spite of this fact, even with the ethmoid in position on 
the superior maxillary we note that a large portion of the max- 



Lachrymal bone 


■Capsule of ethmoid 


Inf. turb. 


Ascending process, 
of sup. max. 


Fig. 8. —Superior maxilla, lachrymal, inferior turbinate and palate bone in normal position. 


illaris hiatus remains, only the superior part of the V being com¬ 
pletely closed; however, as the middle turbinate more or less 
screens the underlying structures which enter into the formation 
of the partition between the nose and antrum, it will be necessary 
to partially remove this structure in order to intimately study the 
relations of those parts (Fig. 11). 

After the middle turbinate has been removed we immediately 
note that the orifice leading into the antrum is considerably smaller, 
being for the most part closed in by a long flat curved strip of 
bone coming from above and extending downward and backward, 
practically dividing the space (Frontispiece). The shape of 
this process of bone is similar to the blade of a scimiter. This 







GENERAL CONSIDERATIONS. 


7 


process, however, does not hang free in the cavity, but is held in 
position by several projections articulating from the adjacent 
bones. On tracing it to its origin in front we note that it arises 
from the ethmoidal capsule; therefore, it is a portion of the eth¬ 
moid, being known as the uncinate process (processus uncinatus) 
(Figs. 10, 11). 



Frontal 


Ethmoidal portion of 
frontal bone 



Ethmoid capsule 
Superior turbinate 


Palate bone 


Ascending process 
of sup. max. 


Middle turbinate 


Hiatus 


Fio. 9.—Ethmoid, superior maxilla and palate bone in normal position. Frontal in section disarticulated. 


Immediately above, the uncinate process covering the superior 
margin of the maxillary hiatus in a similar manner as the max¬ 
illary process of the inferior turbinate covers the inferior, is situ¬ 
ated a smooth, hollow, semispherical bony projection, which is the 
bulla of the ethmoid (bulla ethmoidalis). (Fig. 10.) The entire 
slit or aperture between the uncinate process and bulla appears 
to lead into the maxillary sinus, but such is not the case, as it is 
completely enclosed by thin bone with the exception of a small 





8 


THE ACCESSORY SINUSES OF THE NOSE. 

hidden ostium at its posterior third. On account of the shape 
of this channel it is described as the hiatus semilunaris, and is of 
interest and importance from the fact that all the sinuses of the 
first series (frontal, anterior ethmoidal, and maxillary) have their 
ostiums associated with or draining into it. 

The orifice between the lateral wall of the nose and the antrum 
is now greatly reduced in size, the remaining opening having the 
shape of a fish-hook, hut broken up into smaller segments by the 
various processes of the bone emanating from the uncinate proc¬ 
ess (Frontispiece). 

The communication between the (1) uncinate process and inferior turbinate and 
the (2) uncinate process and bulla appears to be constant, while that between the 
(3) uncinate process and palate bone is frequently lacking, due to rudimentary 
development. 


Superior turbinate 

Superior nasal passage 
Bulla 

Maxillary process of 
inferior turbinate 

Line for inferior turbinate 


Fig. 10.—Lateral wall of nose with a portion of the middle and inferior turbinates removed. 

This still leaves rather a considerable opening even though it 
is intersected by several bony bridges. In the skeleton this open¬ 
ing is always present, because no more bony tissue enters 
into the foundation of this wall. In the recent state, however, this 
defect in the bony structural development is replaced by the muco- 
periosteum of both the nose and the maxillary sinus in the follow¬ 
ing manner: The mucous membrane and periosteum of the nose 
are so intimately interwoven that it is almost impossible to sepa¬ 
rate them, consequently they form a continuous covering for the 
osseous structure beneath. This membrane in the region of the 


Processus uncinatus 
Line for middle turbinate 


Interior nasal spine . 







GENERAL CONSIDERATIONS. 


9 


uncinate process does not dip down into the empty spaces but 
bridges them over, thereby forming an unbroken wall except in 
one small space between the posterior third of the uncinate process 
and bulla, where an aperture is constant (ostium of the maxillary 
sinus*). Precisely the same condition prevails in the lining mem¬ 
brane of the antrum, and, as a consequence, we have the spaces 
around the uncinate process covered in by two layers of muco- 
periosteum, thereby completing the partition between the nose and 
the maxillary sinus. This part of the nasal wall is known as the 
membranous portion (pars membranacea) and is of surgical im- 



Hiatus semilunaris 


Fig. 11.—Lateral wall of nose showing processus uncinatus and pars membranacea. 


Processus 

uncinatus 


Middle nasal 
passage 

Pars membranacea 


portance on account of its being the thinnest and most resilient 
part of the wall. 

The pars membranacea is bounded above by the bulla, behind 
by the palate bone, below by the insertion of the inferior turbinate 
and in part by the uncinate process, and thereby enclosing the 
posterior portion of the uncinate process in its boundaries (Fig. 
11). When accessory ostiums are present they are situated between 
the processes of the uncinate, usually between that body and the 
inferior turbinate. In this position they are quite accessible to 
sounding and the introduction of a catheter, as they lie at or below 
the inferior margin of the middle turbinate (Fig. 12). 


In making this statement accessory ostiums are not considered. 





10 


THE ACCESSORY SINUSES OF THE NOSE. 


These portions of membrane which lie between the projections of the uncinate 
process are known as nasal fontanelles and when the continuity of the membrane 
is broken, form accessory ostiums. The structural configuration of the uncinate 
process is quite inconstant, particularly regarding its prolongations (any or all 
of them may partially fail), and on this account the fontanelles assume irregular 
shapes in different individuals. The posterior, or that portion lying behind the 
end of the uncinate process, appears always to be constant . 4 

The completion of the lateral wall of the nose is accomplished 
by the addition of the palate and lachrymal bones. The palate 
bone (Figs. 5 and 8) forms the posterior portion of the lateral 


Fig. 12.—Lateral wall of nose showing accessory ostium. 

nasal wall as well as the hard palate. It presents crests for the 
attachment of the inferior and middle turbinates, but is of little 
importance as far as the accessory sinuses are concerned. The 
purpose of this bone seems to be that of further strengthening the 
posterior chambers of the nares. 

The lachrymal bone occupies a space between the (Fig. 19) 
frontal process of the superior maxillary and the lamina papy- 
racea of the ethmoid. This hone is of great surgical importance 



Accessory ostium 


4. Onodi: Fontanelle des mittleren Nasenganges. Arch. f. Lary., Bd. 18, S. 488, 1906. 







GENERAL CONSIDERATIONS. 


11 


chiefly as a landmark in the operation on the ethmoidal cells by 
the orbital route, as the posterior ridge corresponds approxi¬ 
mately to the anterior boundary of the ethmoidal capsule. 

The posterior portion of the lateral nasal wall, that part lying 
behind the extremities of the middle and inferior turbinates and 
below the sphenoid sinus, is formed by the articulation of the 
palate hone with the pterygoid process of the sphenoid (Fig. 13). 



Frontal bone- 


Ethmoidal portion 
of frontal bone 


Ethmoid capsule- 


Superior turbinal 


Ascending process 
of superior - 
maxillary 

Middle turbinate" 


Hiatus maxillaris- 


Palate bone- 


Sphenoid sinus 


Fia. 13.—Ethmoid, superior maxilla and palate bone in normal position. Frontal and sphenoid in 

section disarticulated. 


The lateral nasal wall as now built up, together with the 
mucous membrane, represents three nasal passages and three 
turbinates (inferior, middle and superior). 

1. The inferior nasal passage is limited above by the insertion 
of the inferior turbinate and below by the floor of the nose. 

2. The middle nasal passage lies between the junction of the 
middle turbinate with the ethmoid capsule and the insertion of 



THE ACCESSORY SINUSES OF THE NOSE. 


12 

the inferior turbinate and contains the bulla, hiatus and uncinate 
process. Secretion in this passage indicates disease of the sinuses 
of the first series. 

3. Superior nasal passage: In the strictest sense of the term 
this is really not a true passage, as it is blind in front, being 
formed by an indenture practically dividing the ethmoidal capsule 
in half at its posterior aspect, thus forming two turbinates. 
Neither the middle nor the superior turbinates are separate bones 
or true turbinates, but are dependences of the ethmoid capsule. 
The middle turbinate often takes the form of a semi-solid bone, 
but the superior is but the internal wall of the ethmoid capsule 
containing the posterior ethmoid cells. 


Frequently in the middle turbinate there exist cells which formerly were sup¬ 
posed to be connected with some pathological process, but the authorities of to-day 
have disapproved of this theory, demonstrating that they are merely misplaced 
normal ethmoid cells. Under certain conditions they are subject to disease and 
dilatation or enlargement in precisely the same manner as any other normal 
ethmoid cell under similar conditions. 


This passage is then but a slit in the ethmoid capsule directly 
over the insertion of the middle turbinate, being from one-eighth 
to three-eighths of an inch in height, gradually becoming wider as 
it approaches the choana. It is approximately three-quarters the 
length of the middle turbinate, consequently but half that of the 
middle and inferior nasal passages. The superior nasal passage 
is of importance, as it contains the ostiums of the sinuses of the 
posterior ethmoid cells and is so formed that any secretion issuing 
from these ostiums must find its way over the posterior end of the 
middle turbinate into the choana. 

The olfactory fissure extends from the anterior superior in¬ 
sertion of the middle turbinate to the anterior wall of the sphenoid 
sinus, embracing the internal wall of the superior turbinate in its 
boundaries. It is of surgical importance from the fact that its 
superior boundary is formed by the cribriform plate (lamina crib- 
rosa), and the ostium of the sphenoid sinus is constant in its 
posterior superior boundary. 

It has constantly been the custom to consider the ostium of the sphenoid sinus 
as belonging to, and emptying into, the superior nasal passage. This is anatomi¬ 
cally incorrect, as the examination of several thousand specimens shows that it is 
the exception rather than the rule to find direct communication between these two 
structures. This direct communication can only occur when the recessus spheno- 
* ethmoidalis is excessively deep and the superior turbinate poorly developed. 


GENERAL CONSIDERATIONS. 


13 


It should be borne in mind that the cribriform plate is thinnest 
at its anterior portion, where it is pierced by the olfactory nerves, 
but becomes gradually thicker as it extends backward, as it joins 
the sphenoid it is composed of hard cancellated bone which would 
require considerable force to injure with the ordinary nasal in¬ 
struments. The olfactory nerves during their passage through 
the cribriform plate are enveloped in a prolongation of dura 
mater, which connects more or less intimately with the nasal 
mucosa. This anatomic formation favors the ready transmission 
of infection from the nasal cavities to the meninges. 

The supreme turbinate (concha suprema) lias been described 
by various anatomists, but further than for descriptive purposes 
it is of little importance, being formed by a very shallow furrow 
in the posterior part of the superior turbinate. (Fig. 4.) 

Anatomy of the Nose in Frontal Section. 

It will be remembered that the superior maxillary and ethmoid 
capsule formed the chief structures of the lateral nasal wall. What 
is now their precise relation to the formation of the nose in coronal 
section? This question can be more easily explained by taking 



Fig. 14.—Relation of ethmoid capsule to surrounding structures. (After Hajek.) 


the accompanying schematic drawing as an illustration (Fig. 14), 
and comparing it with a specimen taken from life (Fig. 15). 

We recall that the structures of the lateral nasal wall lying 
above the inferior margin of the middle turbinate on the one 
hand and the uncinate process on the other, belonged to the eth¬ 
moid capsule. The boundaries of the entire capsule are empha- 








14 


THE ACCESSORY SINUSES OF THE NOSE. 


sized by heavy lines in the schematic drawing. Noting this well 
it will be observed that the right and left capsules hang down on 


Crista galli 


Ethmoid 

cells 



Sup.turb. 


Bulla 

Mid. turb. 

Uncin. 

process 

Max. sinus 

Inf. turb. 


Fig. 15.—Cross section behind uncinate process showing relation of ethmoid capsule to surrounding parts. 


c r-sf 



Fig. 16.—Diagrammatic illustration of the ethmoid capsule. Cr. g., crista galli; C. P., cribriform plate; 
P. P., perpendicular plate; L. P., lamina papyracea - , M. T., middle turbinate. 

each side of the nasal septum similar to bags, the inner or septal cor¬ 
ner projecting downward like a slender process. The entire struct¬ 
ure occupies at least half the entire distance between the floor of the 


























GENERAL CONSIDERATIONS. 


15 



Ostium of sphenoid 


Ostium of sphenoid 


Middle turbinate 


turbinate 


Fig. 17.—Section through ethmoid capsule posterior to the hiatus semilunaris. 



Fig. 18.—Frontal, ethmoidal and superior maxilla disarticulated. 


















THE ACCESSORY SINUSES OF THE NOSE. 


nose and the cribriform plate. On analyzing and comparing this 
drawing we find that the superior boundary c. p. (Fig. 16) cor¬ 
responds to the cribriform plate, the projection dividing this plate 
cr. g., the crista galli, the continuation of this process downward \ 
p. p. corresponds to the perpendicular plate of the ethmoid (nasal 
septum). The external orbital boundary, 1. p., represents the 
lamina papyracea. 



Fig. 19.—Frontal, lachrymal, ethmoidal and superior maxillary, in normal position. 


It will be noted that the lamina papyracea does not meet with or touch the 
lamina cribrosa, being separated by cone-shaped dotted lines. These lines represent 
the articulation of the frontal bone with the ethmoid and will be fully treated upon 
in the section on the anatomy of the ethmoid labyrinth. (Fig. 14.) 

The inferior boundary (b) corresponds to the bulla and the 
long and short projections on the inner side, the middle turbinate 
and superior turbinate respectively. The short heavy line below 
the bulla (p. u.) represents the posterior extremity of the uncinate 











GENERAL CONSIDERATIONS. 


17 


process. When one recalls that this process issued from the ante¬ 
rior portion of the ethmoid capsule in the form of a blade running 
backward beneath the bulla and having no connection with it, the 
seeming peculiar position of this line will be apparent. The 
boundaries of the ethmoid capsule are then the following: 

Above by the frontal bone and sphenoid. 

The laming cribrosa has hitherto shared the superior boundary with the frontal 
m the anatomy of this region. As a matter of fact the roof of the superior anterior 
ethmoidal cells is formed by the orbital portion of the frontal bone (fovea eth- 
moidalis), the posterior superior by the sphenoid (lesser wing). The lamina 
cribrosa leads directly into the olfactory fissure and if a fine wire is passed down¬ 
ward through one of the foramina it will always emerge in the nasal fossa and 
never into an ethmoidal cell unless dehiscence of the bone is present. This state¬ 
ment is borne out by the examination of hundreds of specimens. 

Externally by the lamina papyracea (orbital plate). 

Below by the bulla etlimoidalis. 

Internally by the inner wall of the middle and superior tur¬ 
binates. 

A cross section further back, behind the end of the uncinate 
process, shows little change in the configuration of the parts 
(Fig. 17.) 

We note that the superior turbinate is more conspicuous, the 
middle turbinate shorter, the bulla and uncinate process absent, 
but the ^ize and shape of the ethmoid capsule proper remain 
about the same. 

The ethmoid capsule then occupies all that space lying between 
the inner wall of the orbit and the inner wall of the middle and 
superior turbinate. Its exact relationship to the orbital wall is 
shown in Figs. 18, 19. 

Topographical Anatomy of the Hiatus Semilunaris. 

It has been previously shown that the hiatus semilunaris is a 
more or less shallow curved duct situated in the middle nasal 
passage between the processus uncinatus and bulla and in normal 
cases is always covered by the anterior third of the middle tur¬ 
binate. (Figs. 20, 21.) The hiatus is not of constant width, but 
has a larger diameter in the depth than superficially, i.e., on cross 
section it is pear-shaped. (Fig. 22.) It also gradually becomes 
wider as it extends downward, as its widest part is in direct rela¬ 
tion to the maxillary ostium. From this fact the depth of the 




18 


THE ACCESSORY SINUSES OF THE NOSE 




Fig. 21. —Relation of sinuses and hiatus semilunaris to lateral wall of the nose. (Modified after Hajek.) 













GENERAL CONSIDERATIONS. 


19 


structure has been termed the infundibulum, while the whole 
structure, including the depth, the hiatus semilunaris. 

This division of the nomenclature has been the source of endless confusion. 
Heymann and Ritter * * 5 but recently have attempted to elucidate the entire subject 
by applying the term infundibulum to that portion of the hiatus which directly 
communicates with the frontal sinus. Hajek 8 has taken exception to this classifi¬ 
cation and clings to the old accepted meaning of the term. 

The anterior and superior end of the hiatus leads into the 
frontal sinus in two ways, which Hajek terms the typical and 
atypical. (Figs. 23 and 24.) 


Sup.turb* 

Bulla 
Hiatus semilun. 

Proc. unciform. 
Mid. turb. 

Max. sinus 

Inf. turb. 


Fig. 22.—Transverse section through the middle of the uncinate process and bulla, showing 
pear shape of hiatus semilunaris. 

1. By direct continuation without the intervention of any hin¬ 
dering structure. (Fig. 23.) 

2. By the hiatus ending blind hut the continuation of the canal 
occurring above and immediately to the inside. (Fig. 24.) 

The author would be inclined to refer to the latter as the typical, as the vast 
majority of specimens show this blind ending of the hiatus. Uffenorde 7 has demon¬ 
strated two further ways by which the hiatus may end anteriorly, but as they 
are distinct anomalies they will be referred to later (see Anatomy of ethmoid 
labyrinth). 

5. Heyman & Ritter: Zur Morphologie und Terminologie des mittleren Nasengan- 

ges. Zeitschr. f. Laryngologie, Bd. 1, S. 1, 1909. 6. Hajek: Die Nebenhohlen der Nase., 

S. 39, Note, 1909. 7. Uffenorde (3), S. 4. 








20 


THE ACCESSORY SINUSES OF THE NOSE. 


The posterior end of the hiatus usually ends in a deep furrow, 
the maxillary ostium coming in, as it were, from the side and 
usually at an appreciable distance from the posterior extremity. 
Much has been said regarding the direct passage of purulent 




Figs 23 and 24.—Schematic illustration of the two formations of the hiatus semilunaris. frontal 

sinus; o.e., ethmoid ostium; o./., frontal ostium; h.s., hiatus semilunaris. (After Hajek.) 

materials from the frontal sinus into the maxillary. That this can 
and does occur under certain circumstances must not be denied, 
but it depends entirely upon the anatomical configuration of the 
uncinate process. If this structure is broad and obliquely situated 


Frontal sinus 


Stylus from 
frontal into 
maxillary sinus 


Maxillary sinus 



Fig. 25.—Direct connection between the frontal and maxillary sinuses through 
an abnormally deep hiatus semilunaris. 


so that it forms a trough with the lateral wall, the maxillary ostium 
being at the end of this passage, naturally any fluid coming from 
above must be directed along the line of least resistance and find 
its way to this ostium. The size of the ostium also exerts no little 
influence in allowing the passage of liquids. (Pig. 25.) The ostiums 








GENERAL CONSIDERATIONS. 


21 

of the anterior ethmoid cells are variously situated. One, how¬ 
ever, is practically constant, being situated directly between the 
bulla and attachment of the middle turbinate. (Fig. 26.) The 
length of the hiatus is variable, depending upon the configuration of 
the parts in the frontal region. 



Fig. 26.—Lateral wall of the nose with anterior half of the middle turbinate removed. 


Mucosa of the Lateral Nasal Wall. 

The mucous covering of the ethmoidal capsule and inferior tur¬ 
binate is continuous and similar in appearance, but presents dif¬ 
ferent characteristics. Over the inferior turbinate it is tough and 
may be several mm. thick, owing to the presence of numerous muci¬ 
parous glands, swell bodies and connective tissue, while that por¬ 
tion that covers the ethmoid capsule and middle turbinate is tender 
and quite thin. The blood supply is derived from the spheno¬ 
palatine branch of the internal maxillary artery and the anterior 
and posterior ethmoidal arteries. (Plate la.) The spheno-palatine 
artery supplies the floor of the sphenoid sinus. The ethmoidal 
arteries supply the ethmoid capsule and the anterior portion of 
the lateral nasal wall. 





22 THE ACCESSORY SINUSES OF THE NOSE. 

THE DEVELOPMENT OF THE ACCESSORY SINUSES (POST- 
EMBRYONIC).* 

Maxillary Sinus .—In the new-born the antrnm is present, al¬ 
though in miniature proportions, occupying a space internally to and 
not below the orbit. * * * 8 (Fig. 27.) Its actual shape and size devoid 
of membrane are approximately those of a small bean. (Figs. 
28, 29.) In the recent state, however, the lining membrane is very 
thick in proportion to the size of the cavity, almost filling its lumen 
and giving it a slit-like appearance. The floor is relatively high, as 
it barely reaches the attachment of the inferior turbinate. 



It would appear that the sinus lies in closer relation to the orbit than to the nose. 
Such is not the case. Even in the nine-month embryo a needle can be passed through 
the inferior nasal passage into the sinus if the point be sufficiently elevated. The 
alveolus occupies the same relation inferiorly as does the orbit superiorly. 

The subsequent growth of the antrum occurs through the down¬ 
ward development of the alveolar process, and lateral infra-orbital 
absorption of cancellous bone through the walls of the cavity, and 
does not assume its permanent shape until after the eruption of 
the permanent teeth, with complete development of the upper jaw. 
It, therefore, reaches its full size between the fifteenth and eigh¬ 
teenth years. 

*For an exhaustive treatise on this subject see Onodi: Die Nebenhohlen der Nase 

beim Kinde. Wurzburg, 1911. In this work the successive stages of sinus development 

from the six and a half months’ foetus to adult life are depicted in 102 plates. 

8. Reschreiter: Zur Morphologie des Sinus Maxillaris. Stuttgart, 1878. 













PLATE L 



A, Blood supply of lateral nasal wall. Spheno-palatine artery posteriorly. Anterior nasal and ethmoidal 

arteries above. (After Sobotta.) 



B, Nerve supply of lateral nasal wall. (After Sobotta.) 




















GENERAL CONSIDERATIONS. 


23 


Frontal Sinus .—This cavity is not present in the newly born, but 
makes its appearance in the orbital plate between the end of the first 
and beginning of the third year, 9 and up to the sixth or seventh year 
reaches only the size of a pea. 10 It does not commence by direct re¬ 
absorption of the frontal bone, but by an upward expansion of an air 
passage from the anterior ethmoidal labyrinth, which gradually 
forces its way into the diploe of the squamous portion of this bone. 
At the end of the seventh to ninth years this sinus may be recognized 
as a distinct separate cavity above the root of the nose internal to 
the supra-orbital ridge. (Fig. 28.) 

Ascending 
process 


Unerupted 

tooth 

Right maxilla 

Figs. 28 and 29.—Superior maxilla of foetus at birth, showing size of maxillary sinus. 

Ethmoid Labyrinth .—These cells are also present at birth (Fig. 
27), being hollowed out in the foetus at the third embryonal month 
and develop simultaneously with the frontal sinus. The latter is 
but an offshoot from the ethmoid, which forces its way into the 
diploe of the nasal portion of the frontal bone. 11 Curran 12 has 
shown that all of the cells are present at birth as well as- those which 
afterward go to form the sphenoid and ethmoid. He dissected 
foetuses from three and one-half months until birth and was able to 
form a continuous picture, thereby drawing reliable conclusions. 
In fourteen heads about the same number of cells were present that 
are found in the adult (nine to fourteen). 

Sphenoid .—At birth this structure is but a faint depression in 
the cancellated tissue of the body of the sphenoid. It begins to 
develop about the fourth month, and is fully formed about the 
sixteenth year. 

Coffin 9 says it is a distinct cavity at the end of the first year. 
While this may be true in certain instances, it is usually not well 
marked until the second year, when reabsorption of the body of the 
sphenoid bone commences, and by the time the sixth year is reached 

9. Coffin: The Development of Acc. Sin. of Nose. Am. Jr. of Med. Sciences, Feb., 1905. 

10. Steiner: Ueberd.Entwick. d.Stirnhohle. Langenbeck’sArch.f.klin.Chir., Bd. 13,S. 144, 

1872. 11. Spiess: Die Untersuchungsmethoden der Nase und ihrer Nebenhohlen. Heymann’s 
Handbuch, S. 238, 1900. 12. Curran: The Ethmoid Cells at Birth and their Development 

during Fetal Life. Boston Med. and Surg. Joum., vol. 59, p.565,1908. 







24 


THE ACCESSORY SINUSES OF THE NOSE. 


the sinus cavity has extended well posteriorly towards the sella 
turcica. 13 (Fig. 29a.) 

RATIONALE OF THE PHYSIOLOGICAL DEVELOPMENT OF THE AC¬ 
CESSORY SINUSES. 

Many theories have from time to time been advanced to explain 
this process. Among others the following appear to be the more 
feasible: 1. Reabsorption of the hone due to variations in air 
pressure, particularly that of expiration. 



Ost.tub.cxud. 


F. pha.T\too.s. 


Fig. 29a.—Specimen from a child, eight years, eight months and one day old. Sagittal section cut 1 mm. 
to the right of median 1 ne. Pneumatization of the sphenoid bone is less extensive than is usually found 
at this age. S. front., sinus frontalis; Rec. sph. eth., recessus sphenoethmoidalis; S. sph., sinus sphenoi- 
dalis; Hypoph., hypophysis; Ton. phar., tonsilla pharyngea; F. phar. bas., fascia pharyngobasilaris; 
Ost. tub. aud., ostium pharyngeum tubse auditivae.—(Davis’s ‘‘Nasal Accessory Sinuses in Man.”) 


Coffin 9 appears to have been the first one to advance this theory when he stated 
that the development of the sinuses may be due to expansion under pneumatic pres¬ 
sure causing resorption of the cancellous tissue, as this development manifests itself 
at the age at which children begin blowing the nose. Frers, 14 apparently independent 
of Coffin, comes to the same conclusion, basing his assertion on the following reasons: 

1. The principal growth of the sinuses occurs after respiration sets in. 

2. According to the law of nature, organs which cease to functionate, atrophy. 

3. The sinuses show similarity to the other cavities which are influenced by air 
pressure (alveoli of lungs). 


S i rant 


tie a. sph.. eth. 
S. sph. 


Hypoph. 


TotvphaJV 


13. W. B. Davis: Development and Anatomy of the Nasal Accessory in Man (Fig. 27). 
Saunders, Philadelphia, 1914. 14. Frers: Studien liber die postembryonale Entwickelung 

der Nebenhohlen der Nase. Vehr. d. Vereins. deutscher Laryn., S. 191, 1909. 








GENERAL CONSIDERATIONS. 


25 


4. The constant presence of changing pressure in the sinuses. (Inspiration 
negative, expiration positive.) 15 

5. The direction of the inspiratory and expiratory streams in relation to the 
anatomical formation of the nose. 

Both Coffin and Frers refer to the fact that the sinuses are poorly- 
developed in children with adenoids; they consider this due to the 
lack of normal air pressure in the nose during expiration. 

Killian 16 does not agree with Frers in any of his points, and says the secondary 
enlargement of the sinuses must result from some deeper lying phylogenetic influence. 

PHYSIOLOGY OF THE ACCESSORY SINUSES. 

Numerous theories have been advanced regarding the precise 
function of these cavities, and even at the present moment many 
authorities will hold almost directly opposite views as to their 
significance. The theories which have been advanced from time to 
time and have the most semblance of probability are: 

1. Remains of certain rudimentary structures which in lower 
animals serve as important adjuncts to the sense of olfaction. 17 

Certain of the lower animals possess an exceedingly keen sense of smell. This 
has been shown to be due to accessory olfactory ridges (Reichwulste) situated in the 
frontal, sphenoid, and maxillary sinuses. 17 The ethmoid labyrinth cannot enter into 
the question, as it is found only in man and the anthropoid apes. 

2. An adjunct to olfactory function by evenly distributing the 
inspired air in the olfactory region. 

This theory was advanced by Braune and Clasen. 18 Paulson (1882) and Hartz 19 
do not accept this theory, stating that those animals which do not possess any power 
of olfaction often have the large sinuses. Preyer (1884) also combats this theory 
with the argument that small children and the lower apes have practically no sinuses, 
yet possess the keenest sense of smell. 

3. To lighten the bones of the skull in order that proper balance 
may be maintained—Vesalino (1542)*, Schneider (1655), Bartholi- 
mus (1658), Highmore (1861), Muller (1840).* 

Braune and Clasen 18 object to this theory, on the ground, if the sinuses were 
filled with spongy bone, the total weight would be raised only one per cent. Schwalbe 
(1887) answers this argument by stating that the head is so evenly balanced that this 
slight increase would tend to interfere with the proper equipoise. Zarnico (p. 82) re¬ 
jects the theory as unsound, by pointing out that children have no sinuses but still are 
perfectly able to balance their heads. 

Braune and Clasen 18 have computed the loss of weight which the skull would 
undergo by substituting air cavities for solid bone and found that the total weight loss 
was one per cent. Schwalbe (1887) claims, however, that this small loss of weight 

15 . Neumayer: Ueberden Luftwechsel in den Nebenhohlen. Mon. f. Ohrenhk., S. 504, 
1901. 16 . Killian: Discussion zu Frers (14). 17 . Ingersoll: The Function of the Accessory 

Cavities of the Nose. Ann. Otol., Rhin. & Laryng., p. 757, 1906. 18 . Braune & Clasen: 

Die Nebenhohlen der Menschlichen Nase in ihre Bedeutung fur den Mechanismus des 
Riechens. Zeit. f. Anat., Bd. 2 , S. 1 , 1877. 19 . Hartz: Physiology of Nose and Sinuses. 

Laryngoscope, p. 958, 1909. _ r . 

♦For the complete literature of the ancients and older writers see J. Wright s History 
of the Nose and Throat, p. 165. 




26 


THE ACCESSORY SINUSES OF THE NOSE. 


considerably influences the poise and counterpoise of the head, as it was entirely 
limited to the anterior portion (mostly in the bones of the face). 

4. Imparting resonance to the voice—Speigel (1645), Vol- 
tini (1888). 

This was at first disapproved, but later authorities are becoming more and more 
inclined to accept this as one of the definite functions of the sinuses. Howell 19a 
states that the Maori of New Zealand possess peculiarly dead voices which re¬ 
searches show is due to an under-development of the accessory sinuses. 

5. Secreting mucus for the purpose of keeping the nasal cham¬ 
bers moist—Haller (1763), Bidder (1845). 

This theory has now largely fallen into abeyance since it was shown that the 
mucous membrane lining of the sinuses is practically devoid of glandular tissue so 
that sufficient mucus for this purpose cannot possibly be secreted, moreover, the 
unfavorable situations of the ostia (except the frontal) for the outflow of the se¬ 
cretion precludes the possibility of their having this function. (Luschka, 1867.) 

6. Adjunct to respiration. Moistening the inspired air. 

Role of the Sinuses During Respiration. 

Schaeffer 19b rejects these theories and states that until further 
information is obtained the function, of these cavities must remain 
more or less obscure. 

The extensive experiments of Braune and Clasen 18 have defi¬ 
nitely shown that a certain amount of air change takes place in the 
sinuses during respiration. The volumetric changes are not in ratio 
to the amount of inspired air passing through the nasal chambers, 
but depend more upon the degree of one inspiration, thus, for ex¬ 
ample, in the maxillary sinus during ordinary respiration the air 
change is relatively small, while in forced inspiration, particularly 
as the alae of the nose are more or less sucked in, the rarefaction of 
the air in this sinus will equal that in the nasal passages. Polyps, 
polypoid hypertrophies and swellings around the ostia naturally 
exert considerable influence on this physiological exchange of air. 20 

INTRA-NASAL AIR PRESSURE DURING INSPIRATION AND EXPIRATION. 

1. Ordinary inspiration — 6 mm. to — 8 mm. H.,0 

2. Ordinary expiration + 4 mm. to + 6 mm. H~0 

3. Forced inspiration —50 mm. to — 65 mm. H^O 

4. Forced expiration -f- 30 mm. to + 35 mm. H~0 

NORMAL MECHANISM OF DRAINAGE. 21 

Under normal conditions the accessory sinuses of the nose are 
capable of self drainage for the following reasons: 

1. The lining mucous membrane is composed of ciliated epi- 

19a. Howell: Voice Production from the Standpoint of the Laryngologist. Ann of 
Otol., Rhin. and Laryn., p. 643, September, 1917. 19b. Schaeffer: The Nose and Olfact¬ 
ory Organ, p. 350. Blackiston’s, 1920. 20. Eckley: On the Accessory Sinuses. Chicago 

Med. Recorder, vol. 26, p. 245, 1904. 21. Yankhauser: The Drainage Mechanism of the 

Normal Accessory Sinuses. Laryngoscope, p. 518, 1908. 




GENERAL CONSIDERATIONS. 


27 


thelium, the motion wave of the cilia being always directed toward 
the ostium of the sinus. 

2. At every position of the body certain of the ostia are at the 
lowest portion of the sinus, thus in standing or sitting the ostium of 
the frontal sinus is low, on lying down the maxillary sinus. 

This accounts for the dissimilarity of the subjective symptoms 
often noted in affections of individual sinuses; thus a frequent 
symptom of chronic frontal sinusitis is neuralgia over the orbital 
region regularly appearing at a certain time in the morning, con¬ 
tinuing several hours, then ceasing as suddenly as it appeared. The 
explanation of this phenomenon is as follows: During the night 
while the patient is in the recumbent position the frontal ostium 
lies in an unfavorable position to allow the continually forming 
secretion to escape, therefore, it accumulates in situ. In the morn¬ 
ing, when the erect position is assumed, the mucous membrane 
around the ostium is more or less swollen and congested from the 
irritation of the secretion as well as the equalization of blood 
pressure, consequently stagnation and engorgement result in the 
sinus. As soon as actual pressure occurs, neuralgia appears and 
continues until the ostium, either through pressure of the secre¬ 
tion or amelioration of the congestion, becomes sufficiently patu¬ 
lous to allow the partial or full escape of the secretion. Drainage 
is thus established with instant cessation of the neuralgia. The 
size of the sinus, profuseness of secretion and virulence of the 
infection can exercise great influence on the severity or duration 
of the neuralgic attack. 

The maxillary sinus under the same circumstances may exhibit 
totally different characteristics. Thus, a patient presents himself 
on a morning for examination with the classical symptoms of 
maxillary sinusitis except no secretion is seen by rhinoscopy; how¬ 
ever, the history of a profuse discharge in the nasopharynx is 
obtained. This must usually be drawn backward and expecto¬ 
rated. The explanation of this peculiarity lies in the drainage 
mechanism. During the day the sinus secretes an amount which 
fills the cavity, and, as the ostium is situated at the superior por¬ 
tion, the secretion only escapes drop by drop, while the patient 
is in the upright position. As the patient lies on the sound side 
during the night, the ostium lies in the most favorable situation 
for drainage, and this, together with the action of the cilia, m a 
greater or lesser period of time depending upon the consistency 
of the secretion, enables the sinus to rid itself of its pathological 
contents, frequently by a system of siphonage, especially if the 




28 


THE ACCESSORY SINUSES OF THE NOSE. 


secretion be viscid. On awakening in the morning, this mass, being 
free in the nasal passages, is either blown or hawked out en masse , 
and at the examination, a few hours later, no trace of secretion is 
to be found in the nose, as in the meantime the mucous membrane 
of the antrum has not had the opportunity to secrete a sufficient 
amount to fill and overflow. 

The drainage of the sphenoid is similar to that of the antrum, 
but on a much smaller scale. The drainage mechanism of the 
ethmoid cells may be either the simplest or the most complicated 
of the accessory cavities of the nose,—the simplest when the 
ostium is situated in the lowest portion of the cell and empties 
directly into one of the nasal passages; the most complicated 
when one cell empties into another and into a third or fourth and, 
finally, empties into the nose. 

BACTERIOLOGY OF THE ACCESSORY SINUSES. 

Before considering this phase of the subject it is necessary to 
ascertain whether the sinuses under normal circumstances act as 
a habitat for micro-organisms. It was formerly considered that 
such was the case, but later investigations have proved this 
assumption false. 22 23 

Torne 24 demonstrated that the healthy sinuses of cadavers 
which had not been dead over two hours were without exception 
sterile, as the following table shows: 

Examination of the Maxillary and Frontal Sinuses at Various Times 

After Death. 


Time of examination 

No. of 

Bacteriological 

after death. 

cases. 

findings 

45 minutes. 

.1 

None 

50 minutes.. 

. 1 

None 

1 hour . 

. 5 

None 

1 hour 10 minutes. 

. 3 

None 

1 hour 15 minutes. 

. 4 

None 

1 hour 30 minutes. 

. 2 

None 

1 hour 45 minutes. 

. 2 

None 

1 hour 50 minutes. 

. 2 

None 

2 hours 20 minutes. 

. 1 

None 

3 hours 5 minutes. 

. 1 

Bacteria in left maxillary 


22. Torne: Das Vorkommen von Bakterien und die Flimmer-bewegung in den Neben- 
hohlen der Nase. Central, f. Bakteriologie, etc., Bd. 33, No. 4, 1903. 23. Lewis and 

Logan Turner: Suppuration in the Accessory Sinuses of the Nose. A Bacteriological and 
Clinical Research. Edinburgh Med. Journ., Nov., 1905. 24. Torne: Die Bakteriellen 

Verhaltnisse der Nebenhohlen und liber ihre Schutzmittel gegen Bakterien. Nord. Med. 
Arkiv., H. 1, No. 2, 1904. 













GENERAL CONSIDERATIONS. 


29 


Examination of the Maxillary and Frontal Sinuses at Various Times 
After Death.— Continued 


Time of examination No. of 

after death. cases. 

4 hours 15 minutes. 1 

4 hours 30 minutes.1 

6 hours 20 minutes. 1 

9 hours 10 minutes. 1 

25 hours . 1 


Bacteriological 

findings. 

Bacteria in left maxillary 
Bacteria in right and left frontals 
Bacteria in right maxillary 
Bacteria in right and left maxillary 
Bacteria in right and left maxillary and 
frontals. 


In consideration of these findings one must naturally infer that 
bacteria do not find their way into healthy sinuses during life. 
Such, however, is not the case, as the further experiments of the 
same author confirm. 22 


The heads of freshly-slaughtered calves were opened in such a manner that 
the nasal wall of the maxillary sinus with the ostium was exposed. Small portions 
of finely-powdered lampblack were strewn over the mucosa of the sinus and results 
noted by means of a strong reading-glass. The lampblack particles were seen to 
slowly move toward the ostium (at the speed of 1 cm. per minute) and finally 
disappear into the nose. This was found to be due to the motion of the ciliated 
epithelium lining the sinus, as after a short time the motion became more and more 
feeble and finally ceased altogether. 

It has been proved by physiologists that the sinuses are aerated 
during every nasal respiration. It stands to reason that during 
these respirations some micro-organisms must find their way into 
and become lodged upon the mucosa of the sinuses. As soon as 
this occurs the cilia of the healthy sinus immediately begins its 
expulsion, as the presence of this minute foreign body stimulates 
it into great activity. 


Tome carried his investigations further by experiments with the normal 
secretion of the maxillary sinus as to its germicidal action. This was accomplished by 
opening the antra of cadavers immediately after death under antiseptic precautions 
and gently scraping the antral mucosa with a dull, spoon-shaped curette, thus ob¬ 
taining a small portion of mucoid secretion. A freshly-prepared growth of anthrax 
bacilli was added to this and results noted. After some eighteen experiments it was 
conclusively proved that if the secretion did not possess strong bactericidal power 
it was distinctly inhibitory to the further growth of the micro-organisms. 

We must then accept that the normal sinuses are protected 
against the invasion of bacteria in two distinct ways: 1. By the 
action of the cilia of the mucosa, which continually wave toward 
the sinus ostium. 2. By the secretion of the glands situated in 
the mucosa, which possesses a decided inhibitory power to the 
further growth of the invading germ. Both of these conditions 
must be overcome before infection of the sinuses can occur. 










30 


THE ACCESSORY SINUSES OF THE NOSE. 

Suppurative inflammations of the sinuses are the direct result 
of bacterial invasion, hut whether these micro-organisms act 
primarily directly on the healthy mucous membrane or whether 
they require that the vitality of the mucous membrane first be 
lowered by some general systemic disease appears to be more or 
less of a mooted question. 

Both of these theories appear to be tenable. The first seems to have been 
proven correct by the investigations of Weichselbaum,* * 5 E. Frankel, and 
Dmochowsky, 27 who demonstrated the presence of true diphtheritic membrane on 
the mucous membrane of the maxillary sinus in cases of diphtheria. The second 
theory is substantiated by the numerous cases occurring after certain infections to 
which one can assign no definite cause. The findings of E. Frankel and Wert- 
heim 28 of evidences of non-tubercular sinus disease in every third phthisical corpse 
would also add to the probability of this theory.* E. Frankel 26 also found the 
diploeoccus pneumoniae as the predominating organism in pus from the sinuses 
of individuals who had died of influenza. Zarnico 2a lays particular stress on 
secondary infection occurring in the accessory sinuses, and states that one can 
readily conceive how a sinus affection may occur even in the course of influenza 
without being dependent upon the specific organism of the disease (influenza). 

The point of infection seems to play an important role in this 
condition, as the bacillus of influenza has long been considered a 
frequent causative factor from purely a local point of view. This 
theory of local infection in all cases was generally accepted until 
Killian 30 conclusively demonstrated that in scarlet fever infection 
resulted through the blood or lymph-channels. Since that time 
other observers have confirmed his findings. Since Weichselbaum 
first began his investigations, in 1888, up to the present time, it 
seems to have been the general endeavor to associate one partic¬ 
ular micro-organism with all sinus suppuration. Thus the pneu¬ 
mococcus of Frankel and the influenza bacillus for a long time held 
sway; other micro-organisms, as the diploeoccus pneumoniae, were 
soon added to these, until now practically all those of suppuration 
have been found and described as causative factors of this disease. 

According to Hajek 31 and Zarnico, 29 they appear as follows in 
their relative frequency to the causation of disease: 


25. Weichselbaum: Ueber seltenere Localization des pneumonischen Virus. Wien, 
klin Woch., S. 573, 659, 1888. 26. E. Frankel: Beitr. z. Path. u. iEtiol. d. Nasenneben- 
hohien-Erkrankungen. Virchow’s Arch., Bd. 143, S. 92, 1896. 27. Dmochowski: Beitrag. 

z path. Anat. u. ^Etiol. d. entz. Processes im Antrum Highmori. Arch. f. Laryng., Bd. 3, S. 
255 1895. 28. Wertheim: Tuberculosis. Beitrage z. Path. u. klin. d. Erkrank. d. Nas- 

ennebenhtihlen. Arch. f. Lary., Bd. 11, S. 169, 1901. 29. Zarnico: Die Krank. der Nase 
und des Nasenrachens, S. 605, 1910. 30. Killian: Die Erkrankung der Nebenhohlen 

bei Scharlach. Zeit. f. Ohrenhk., Bd. 56, S. 189, 1908. 31. Hajek (6), S. 3, 1909. 

* This is not substantiated by investigations upon the living. See R. H. Skillern: 
Exploratory Needle Puncture of the Maxillary Sinus upon One Hundred Tubercular Indi¬ 
viduals. Journ. A. M. A., Sept. 21, 1912, Part 2. 




GENERAL CONSIDERATIONS. 


31 


Hajek. 

1. Influenza bacillus. 

2. Diplocoecus pneumoniae. 

3. Staphylococcus pyogenes aureus and 

albus. 

4. Streptococcus pyogenes. 

5. Bacterium coli. 

6. Pseudo-diphtheria bacillus. 

7. Bacillus pyocyaneus. 

8. Bacillus Friedlander. 

9. Meningococcus intracellularis. 


Zamico. 

1. Diplocoecus lanceolaitus (pneumo¬ 

coccus). 

2. Staphylococcus and streptococcus. 

3. Influenza bacillus. 

4. Pseudo-diphtheria bacillus. 

5. Friedlander’s capsule bacillus. 

6. Meningococcus intracellularis. 

7. Bacterium coli. 

8. Bacillus pyocyaneus. 

9. Bacillus pyogenes feetidus. 


Lewis, 32 in a much later investigation, gives the following, but 
not especially in their order of occurrence: 1. Staphylococci pyog¬ 
enes, aureus, citreus, and albus. 2. Streptococci. 3. Pneu¬ 
mococci. 4. Micrococcus catarrhalis. 5. Coliform bacilli. 6. Diph¬ 
theroid bacilli. 7. Mesenteric group. 8. Dental organisms. 
8. Obligate anaerobes. 10. Miscellaneous group. The Bacillus 
fusiformis of Plaut-Vincent has recently been reported as the cause 
of ethmoid abscess by Brandt. 32 * 

Babcock 32b in a comprehensive investigation reports the fol¬ 
lowing findings: 

ACUTE CASES. 


Pneumococcus: 

Type not determined. 5 

Group II . 9 

Group III . 3 

Group IV .15 Total 32 

Streptococcus: 

Haemolytic. 3 

Non-haemolytic. 2 Total 5 

Staphylococcus: 

Aureus . 13 

Albus.17 Total 30 

B. Influenza . 4 

M. Catarrhalis . 2 

A. Diphtheroid Bacillus. 2 

B. Coli Communis. 2 

B. Fecalis Alkaligenes. 3 

B. Aureus. 1 

B. Proteus . 3 

B. Subtilis. 1 

No growth. 4 


32. Lewis: The Micro-organisms Present in Suppuration of the Accessory Sinuses of 
the Nose. Journ. of Path, and Bacterioh, vol. 16, p. 29, 1911. 32a. F. H. Brandt: Eth¬ 
moidal Abscess Caused by the Bacillus fusiformis of Plaut-Vincent. Laryngoscope, p. 1136, 
1913. 32b. Babcock: Bacteriological and Clinical Aspects of Infection of the Accessory 
Sinuses of the Nose. Laryngoscope, p. 527, 1918. 




















32 


THE ACCESSORY SINUSES OF THE NOSE. 


CHRONIC CASES. 

Pneumococcus: 

Type not determined. 1 

Group II... 1 

Group IV.. 4 Total 6 

Streptococcus: 

Haemolytic . 15 

Non-hsemolytic. 4 Total 19 

Staphylococcus: 

Aureus .IS 

Alb us.20 Total 38 

B. Influenza . 2 

B. Mucosus Capsulatus.... 5 

A. Diphtheroid Bacillus . 4 

B. Coli Communis. 2 

B. Fecalis Alkaligenes . 3 

B. Aureus . 3 

B. Proteus . 1 

M. Tetragenus. 3 

B. Subtilis. 1 

No growth. 1 

Pure growth of one organism was as follows: 

ACUTE CASES. 

Pneumococcus.24 

Streptococcus . 2 

Staphylococcus .10 

B. Aureus. 1 

Diphtheroid Bacillus. 1 

M. Catarrhalis . 1 

CHRONIC CASES. 

Pneumococcus. 3 

Streptococcus . 4 

Staphylococcus.15 

B. Mucosus Capsulatus . 1 

Diphtheroid Bacillus. 1 

M. Tetragenus. 1 


According to the investigations of the author, these micro-organisms do not 
eqntinue the course of the disease uncontaminated, as it is the exception rather than 
the rule to obtain pure cultures from the pus secreted by the sinuses in subacute 
and chronic) cases, as the following table will show. Lewis and Logan Turner 23 
state that in recent cases virulent organisms are met with twice as often as in cases 
of chronic suppuration. 

The reason that one so rarely obtains pure cultures is that most of the chronic 
cases are the result of mixed or secondary infection. In this class of cases it is diffi¬ 
cult, and often impossible, to definitely state which particular organism has been the 
primary cause of the suppuration, granted that the infection has been one of purely 
local origin. Another difficulty lies in the fact that certain organisms grow well on 
one medium, while others require a different kind; thus to cultivate the influenza 
bacillus, a culture of agar smeared with fresh blood is necessary. Neither the 
meningococcus nor the pseudo-diphtheria bacillus will thrive well on this substance, 
therefore different media are required. As the various inoculations should be made 































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GENERAL CONSIDERATIONS. 


33 


with the fresh material, and as the technique is so tedious and varied, one ean readily 
appreciate the difficulties of making accurate observations, much less of obtaining 
reliable conclusions. 

As before mentioned, only in isolated instances were pure cultures obtainable. 
This fact would raise the following question: If the disease was primarily caused by 
one specific micro-organism, when and why did secondary infection take place, and 
what effect has the secondary infection had on the growth and toxicity of the primary 
or infective germ and subsequently the process of the disease ? This seems to be the 
key-note of the course of sinus affections, and one must revert to the etiological 
pathology of the disease in order to elucidate this complex problem. 

As influenza (la grippe) is one of the commonest of the infectious diseases 
which predispose to sinus affections, let us suppose that the patient has recently re¬ 
covered from an acute attack of this malady. The mucous membrane of the upper 
respiratory tract is swollen, congested, and lowered in vitality. The swelling inter¬ 
feres with the action of the cilia by mechanical obstruction, and the congestion pre¬ 
vents the glands from properly secreting, thus leaving the mucosa in a condition for 
favorable micro-organismal invasion. 

The invading bacillus of influenza has found suitable soil for growth in one 
or more of the sinuses, depending upon the virulence of the attacking germ, and 
causes an acute inflammation, with all its attending phenomena. The sinus 
mucous membrane being already swollen and cedematous, there is an outpouring of 
leucocytes and formation of pus, which may or may not drain out, depending 
upon the position and patulency of the drainage canals (ostia). This attack may 
end in one of two ways. 1. The drainage mechanism (ciliated epithelium) of the 
sinus may continually functionate, thus draining off the accumulating secretion, 
inhibiting secondary infection until the natural opsonins of the body conquer the 
invading bacillus and result in a cure of the disease; or 2. Either through swelling 
of the mucous membrane, or unfavorable situations of the ostiums, some inter¬ 
ference with the drainage occurs. The accumulating secretions can only find 
intermittent or insufficient escape; thus partial or complete stagnation results. 
Through the action of the invading bacillus or its toxins, more or less permanent 
changes result in the deeper layers of the mucous membrane. At this point the 
primary infective germ may diminish in virulence and disappear, either through 
the natural resistance of the individual (opsonins having been formed) or from 
some loss of substance in the sinus which is necessary for the growth of that 
particular bacillus. The sinus now offers a suitable soil for secondary infection, 
which immediately occurs; the secondary infective organism overpowers the already 
enfeebled initial micro-organism, re-attacking the tissue and causing the disease to 
become chronic. This same phenomenon is observed in sinus disease following an 
acute coryza by substituting the coryza for the influenza and the ordinary micro¬ 
organisms of suppuration for the influenza bacillus. 

It would be of decided advantage, so far as treatment is con- 
cerned, if one could draw reliable conclusions from the clinical 
appearances as to the particular species of the infecting micro¬ 
organism present. Unfortunately, this is not the case, for, as 
E. Frankel 26 has pointed out, the clinical picture depends less upon 
the particular species of the organism causing the disease than 
upon its virulence, the resisting powers of the tissues, and the 
presence of other forms of bacteria. Peculiar symptoms, however, 
may be indicative of a certain strain, thus, when foetid crust and 
scale formation seem to be predominant, the Bacillus mucosus cap- 


3 


34 


THE ACCESSORY SINUSES OF THE NOSE. 


sulatus is undoubtedly playing an important role. The table fac¬ 
ing page 32, of our own compilation, would also endorse this view. 

CONCLUSIONS. 

1. Pathogenic micro-organisms are never continually present in 
normal sinuses, the mucous membrane, under ordinary normal con¬ 
ditions, being able to render inert and expel the germs. 

2. The primary or infective germ may disappear, allowing the 
germ of secondary infection to continue the disease. 

3. Pure cultures of one variety of micro-organism are rarely 
found in chronic cases of sinus suppuration. 

4. The commonest organisms found are the staphylococcus 
and streptococcus. 

5. Three to five separate and distinct micro-organisms can 
usually be isolated from the same culture. 

6. The culture is nearly always contaminated by one or more of 
the so-called nonpathogenic micro-organisms. 

7. In these cases where several pus-producing germs are found 
it is obviously impossible to definitely state which one has been 
the primary cause of the suppuration. 

8. The type of the micro-organism will often change in the 
course of the disease. During the author’s observations it was . 
frequently observed, particularly in the maxillary sinus, that as 
the disease gradually diminished the character of the organisms 
would also change; thus, in the beginning, when the sinus was first 
opened and drainage established, the fetid, cheesy pus contained 
saphrophytic germs and even individual species (Bacterium coli, 
etc.). These disappeared in the course of a few weeks, leaving the 
more common organisms of suppuration (staphylococcus and 
streptococcus). In acute exacerbations of chronic sinus affection 
it is extremely probable that a fresh infection has occurred, possibly 
from a different species. 

GENERAL AETIOLOGY. 

There exist several distinct processes by which the mucous 
membrane of the accessory sinuses may become diseased. 

1. Through direct invasion of the healthy sinus by patho¬ 
genic bacteria. 

2. Through extension of inflammation from neighboring parts. 

3. Through the blood and lymph-channels. 

4. Through traumatism—exposure to cold, sea bathing, auto¬ 
mobile riding, etc. 

5. Through foreign bodies. 

6. Through contamination from the pus of overlying sinuses. 


GENERAL CONSIDERATIONS. 


35 


1. Through Direct Invasion of the Healthy Sinus by 
Pathogenic Bacteria. 

Under this heading we understand that the mucous membrane 
of the sinus is primarily affected by micro-organisms which find 
their entrance either through the ostiums or through the circu¬ 
latory system, the mucous membrane of the nasal cavity being 
apparently unaffected. 

When considering this theory of entrance through the ostiums it is well to 
bear in mind that the number of pathogenic micro-organisms momentarily present 
in the nasal cavities and sinuses depends upon the environment of the individual; 
thus, in dusty places large numbers may be present, while in great altitudes and 
on the sea the nares are comparatively free. As sinus diseases do not appear to 
be more frequent with individuals who follow occupations necessitating the more 
or less uniform presence of dust-laden air, one must of a necessity give little 
credence to the theory that sudden introduction of pathogenic bacteria into a healthy 
sinus will usually create disease in that sinus. 

D. B. Kyle 33 states that primary involvement of the nasal accessory cavities 
is a very rare condition, although he considers the subjugation of the individual 
to irritating dust vapors or fumes to be an importont predisposing factor. He 
undoubtedly refers to the action of these irritants upon the nasal mucosa. 

There are but four diseases to which this condition can 
be attributed. 

(1) Influenza; (2) croupous pneumonia; (3) diphtheria, and 
possibly (4) erysipelas. 

1. Influenza .—Since the investigations of Lindenthal 34 this disease has gen¬ 
erally been considered the most potent factor in the causation of sinus affections. 
The precise rationale why the bacillus shows especial predilection for the mucous 
membrane of these structures has not yet definitely been explained. Whether the 
infecting organisms gain entrance through the air passages or through the blood 
appears also to be an undetermined question. Weichselbaum 35 states that the 
sinuses are always diseased at some time during the course of influenza. Hajek is 
of the opinion that the sinus disease is rather a sequela than a complication 
of influenza. 

The recent great epidemic (1918) appeared to affect the sinuses as a complica¬ 
tion, the symptoms, however, not being severe enough to draw especial attention to 
the local infections. 353 - It would therefore appear that many cases apparently existed 
which remained unrecognized, as in most of those cases which came to the autopsy 
table the sinuses were found to contain purulent material although during life no 
symptoms were referable to them. 35b Robertson 35c saw inflammatory processes in 
the sinuses of fifteen out of sixteen cases due to the invasion of the influenza bacillus. 

The epidemic, however, has not been followed by sinusitis even approaching the 
extent of former years. Reports from the different portions of the United 

33. Kyle: Acute Inflammations of the Accessory Sinuses, etc. Journ. Am. Med. 
Ass’n, vol. 53, p. 1020, 1909. 34. Lindenthal: Ueber die sporadische Influenza. Wien, 
klin. Wochenschr., April 15, S. 353, 1897. 35. Weichselbaum: Influenza. Wien. med. 

Wochenschr., S. 222, 1890. 35a. Fetterolf: Observations during an epidemic of influenza. 

Trans. Am. Laryng. Ass’n. 1919. 35b. Greene, Coates: Discussion to 35a. 35c. Robert¬ 
son: Influenzal Sinus Disease and its Relation to Epidemic Influenza. Journ. Am. Med. 
Ass’n. p. 1533, 1918. 




36 


THE ACCESSORY SINUSES OF THE NOSE 


States and Army Hospitals confirm this fact. Bryan and Howard 30(3 found about 
thirty cases of active sinus involvement in 1534 influenza patients. This would 
appear to be fairly representative of the whole country. 

2. Croupous Pneumonia* 36 87 38 —There is no longer any question that acute 
inflammatory diseases of the inferior air passages (with the possible exception of 
tuberculosis) strongly predisposed to inflammations within the nasal sinuses. This 
connection has been observed too often to admit any doubt of their association. 
Bacteriological examinations of the diseased sinuses in patients succumbing to this 
affection practically always showed cultures of the diplococcus pneumoniae. 88 

3. Diphtheria ™ 40 —Judging from the examinations of these authors, it is 
certain that the accessory sinuses, particularly the maxillary, are commonly in¬ 
fected during the course of diphtheria. Pearce 40 demonstrated the presence of 
inflammatory changes in 25 out of 39 cases examined post mortem, the bacillus of 
diphtheria being present on both sides in all but three instances. The inflamma¬ 
tion usually presents the same characteristics as that following infection from other 
varieties of micro-organisms, i.e., serous, mucopurulent, and purulent, and only 
in rare instances does it present evidences of the formation of a false membrane. 
There is every reason to suppose that all these cases were secondary to nasal or 
pharyngeal lesions, as no sufficient proof has yet been brought forward that 
primary sinus disease resulting from the invasion of the Klebs-Loeffler bacillus has 
ever existed. 

4. Erysipelas , 41 42 43 —That sinus' disease is often associated with erysipelas has 
been well shown by numerous observers. Some doubt still exists as to the 
precedence of one over the other, but clinical investigations seem to indicate 
possibilities of erysipelas as a primary lesion. Several cases of erysipelas around the 
aim of the nose have also been reported which permanently healed as soon as the pre¬ 
viously-overlooked maxillary sinus disease was operated upon. Unfortunately, the 
bacteriological examinations do not give sufficient data to enable one to arrive at 
reliable conclusions. However, Weichselbaum 41 believed he was able to con¬ 
clusively demonstrate, at several autopsies, the initial lesion in the sinus. 

In these four diseases the sinus affection takes the character 
of the primary disease, while the sinus affections following the 
other infectious diseases are principally due to other micro¬ 
organisms than those responsible for the primary affection 
(secondary infection). 

It is extremely doubtful that a sinus affection is set up by the 
direct invasion of pathogenic micro-organism into a healthy sinus, 
other things being equal, except in very rare instances. The 
mucous membrane of the sinus is normally able to withstand the 


35d. Bryan and Howard: The relation of the ear and accessory sinuses to in¬ 
fluenza during the recent epidemic, as observed at the Walter Reed General Hospital, 
Takoma Park, D. C. Trans. Sec. on Laryng. A. M. A., 1919. 36. Darling: The Accessory 
Nasal Sinuses and Pneumococcus Infections. Journ. Am. Med. Ass’n, Nov. 10, 1906. 
37. Winckler: Bakteriologische Befunde bei Erkrankungen der oberen Luftwege, 
etc. Ver. Siiddeutsch. Lary., S. 109, 1906. 38. Weischselbaum: Ueber seltenere Locali- 
sationen des Pneumonischen Virus. Wien. klin. Wochenschr., S. 573, 659,1888. 39. Wolff: 
Die Nebenhohlen der Nase bei Diphtherie, Masern und Scarlatina. Zeitschr. f. Hygiene, 
Bd. 19, S. 225, 1895. 40. Pearce: Bacteriology of the Accessory Sinuses of the Nose in 
Diphtheria and Scarlet Fever. Journ. of Boston Soc. of Med. Sciences, p. 215, 1898-99. 
41. Weichselbaum: DiePhlegmonose Entziindung der Nebenhohlen der Nase. Wiener 
med. Jahrbiicher, 1881. 42. Luc: Ein Fall von Empyeme durch Erysipelas streptococcus 
verursacht. Deutsch. med. Woch., No. 8, S. 167, 1892. 43. Holmes: Erysipelas and its 
Relation to Purulent Inflammations of the Nasal and Oral Cavities. Trans. Am. Lary. 
Ass’n, p. 48, 1907. 



GENERAL CONSIDERATIONS. 37 

presence of such germs and expel them through the action of the 
cilia, and infection results only when this power has become 
enfeebled or lost, through extrinsic causes (swelling of the mucous 
membrane in infectious diseases, occlusion of drainage channels, 
traumatic injury, etc.). 

Killian 4 * has compared the aetiology of sinus disease to that of the middle 
ear, where the secretion is driven, under pressure, through the eustachian tube to 
the middle ear. This comparison does not appear to be entirely apropos, because 
a medium in the form of a long canal (eustachian tube) exists between the naso¬ 
pharynx and the middle ear. The sinus ostium, a formation corresponding to an 
aperture, can hardly be compared with such a structure. 

It appears to be a mooted question whether the sinus mucosa 
is concomitantly affected with the Schneiderin membrane in, for 
example, an attack of acute coryza, or whether the inflammation 
secondarily follows, being transmitted through the ostium. All 
things being equal, it would seem that the former condition pre¬ 
vails, and that the nasal mucosa, together with its offshoots into 
the accessory cavities, are affected at one and the same time. The 
sinus mucosa, however, need not necessarily be affected to the 
same degree as that of the nasal chambers. 

The mucous membrane, being already inflamed through 
extrinsic causes, furnishes a suitable soil for micro-organisms 
which would otherwise prove harmless. 28 This aetiological factor 
may result from two distinct conditions: (1) infectious diseases 
(including those enumerated above); (2) certain non-bacterio- 
logical diseases of the nasal mucosa which cause swelling and 
intermittently occlude the sinus ostiums. 

(1) Scarlet fever, measles, smallpox, tuberculosis, typhoid 
fever, and cerebrospinal meningitis are frequently complicated, 
or more often followed, by accessory sinus empyema. 

The direct connection between these diseases and local sinus affection is not at 
all clear, but probabilities seem to point to some devitalization of the sinus mucous 
membrane, thereby causing it to be unable to resist the attacks of pathogenic 
pus-producing micro-organisms. 

Singularly enough, in those cases reported the bacteria found in the sinus did 
not necessarily correspond to those causing the general infection, and thus the 
meningococcus has been found in individuals with sinus empyema who never had 
cerebrospinal meningitis. Secondary infection was undoubtedly responsible for 
these apparently anomalous conditions. This is further illustrated by the fact 
that the course and severity of the sinus disease in no way depend upon the 
general condition of the individual nor the particular species of the infecting micro¬ 
organisms. The irreparable missing link in these cases is that a bacteriological 
examination of the purulent secretion from the sinuses was not made during the 
acute period of the attack. 

It is perfectly clear that any condition which would cause general inflamma- 

44. Killian: Die Erkrank. der Nebenhohlender Nase. Heymann’s Handbuch, “Die 
Nase,” S. 992, 1900. 



38 THE ACCESSORY SINUSES OF THE NOSE. 

tion of the nasal mucosa must of a necessity affect the sinuses, for as Zuckerkandl 
first pointed out, the nasal mucosa communicates directly with that of the sinuses, 
and the mucous membranes of the nose and sinuses receive their blood supply 
from the same source. This being true, it necessarily follows that any disease 
causing general acute rhinitis must cause acute general sinusitis. This, however, 
does not explain the fact that all the sinuses are not purulently affected after a 
certain acute infectious disease causing sinusitis, instead of one or two being 
purulently involved, as is, one can almost say, invariably the case. 

Scarlet fever seems to work some particularly malignant influence on the 
sinuses, especially in children, as has been referred to by Hajek, Nager, Herzfeld, 
and Killian. 30 In this disease a great tendency has been observed to affect the 
bone, which often ulcerates entirely through. Kyle 49 states that infection due to 
the pueumonocoecus, streptococcus, or bacillus of influenza shows a marked ten¬ 
dency to bony necrosis. 

(2) Under the heading of non-bacteriological diseases may be 
considered various chronic hyperplasias and hypertrophies of the 
nasal mucosa. These are frequently responsible for disease, par¬ 
ticularly in the frontal and maxillary sinuses. The rationale of 
this is as follows: From repeated attacks of colds or other causes, 
certain portions of the nasal mucosa in the neighborhood of the 
sinus ostium are left cedematous and hyperplastic. At various 
times, particularly when the patient is reclining, the blood-pres¬ 
sure is higher in this locality, with consequent swelling and tem¬ 
porary occlusion of that partiular ostium. The sinus mucosa, 
in the meantime, is absorbing the oxygen which is contained in 
the sinus, but, as no more can enter, there results within a condi¬ 
tion of negative pressure, with swelling of and transudation 
through the mucous membrane. Let us accept that, in a longer or 
shorter period of time, the ostium again becomes patulous with 
resolution of the swollen sinus mucosa. The membrane, however, 
does not have time to fully regenerate before the ostium again 
becomes occluded through the same causes. This constant swotting 
and irritation of the mucosa produces inflammatory tissue changes 
which deprive it of a certain amount of vitality, thus causing it 
to offer a suitable culture medium for pyogenic bacteria the first 
time the individual contracts a severe acute coryza. 

Killian 44 does not believe that sinus affections can result through occlusion of 
the ostium, and states that if it does occur the process must be reckoned as a non¬ 
inflammatory affection. He does not mention that this condition strongly predis¬ 
poses to primary infection. Chiari, 60 on the contrary, firmly believed that this is 
one of the most frequent causes of chronic sinus disease, and says, when this 
occlusion continues for some length of time with no infection, the mucous mem- 

45. Zuckerkandl: Normale und pathologische Anatomie der Nasenhohle, Band 1, 
S. 128, 1893. 46. Hajek (6), S. 2, Note. 47. Nager: Ueber die Mitbetheiligung der 

Nasennebenhohlen im Verlauf des Scharlachfebers. Medic. Klinik No. 25, S. 938, 1909. 
48. Herzfeld and Herrmann: Bakteriol. Befund. in 10 Fallen von Kieferhohleneiterung. 
Arch. f. Larv., Bd. 3, S. 143, 1895. 49. Kyle: General Pathologic Processes Associated 
with or Following Infections of the Accessory Sinuses. Ann. Otol., Rhin. and Lary., p. 
775, 1906. 50. Chiari: Die Krankheiten der Nase, S. 215, 1902. 



GENERAL CONSIDERATIONS. 


39 


bran swells and becomes hypertrophic with the formation of polypoid tissues. 
-Kyle a ^ so says the mucous membrane of a sinus is less capable of reproduction than 
the nasal, which accounts for the disease often following- rhinitis. 

2. Through Extension of Inflammation from Neighboring Parts. 

This can occur in two ways: a, By direct extension of inflam¬ 
mation from the nasal mucosa to the sinus. (Continuity.) b. By 
extension of inflammation from the bone to the same mucosa. 
(Contiguity.) 

Extension by Continuity .—Hajek considers this the greatest 
causative factor of sinus disease, 51 and states, even in those cases 
where no trace of inflammation is visible in the nose, it is probable 
that the nasal mucosa primarily was affected. 

The so-called grippal cold (which may or may not be associated 
with the influenza bacillus) is undoubtedly the most potent factor 
in the causation of sinus disease, at least in our country. The 
ethmoid cells seem particularly susceptible to this disease, and 
many cases of ordinary acute rhinitis are in reality acute exacer¬ 
bations of chronic ethmoid cellulitis which the individual suffers 
every winter. The presumption of the primary affection of the 
mucosa is assumed. 

Killian 44 believed that in the majority of cases associated with acute coryza 
the sinuses are primarily diseased, as in influenza. This opinion is endorsed by 
Zarnieo . 63 It seems to me this matter may be elucidated if one accepts that the 
nasal musosa is primarily affected, the inflammation of the sinus mucosa closely 
following. The nasal mucous membrane finally throws off the disease while the 
inflammation continues in the sinus because of its unfavorable anatomical con¬ 
figuration. 

Extension by Contiguity .—This form is principally observed 
in the maxillary sinus, and results from carious roots of the teeth 
causing periosteal and subperiosteal abscesses, particularly those 
which come into nearest contact with the floor of the sinus (second 
premolar and first molar). Formerly this condition was con¬ 
sidered a most prolific cause of maxillary sinus empyema, but 
later years have shown that only a small percentage of cases 
(about twenty-five per cent.) are due to this origin. 

3. Tuberculosis, Syphilis, Malignant Neoplasms, and 
Latent Empyema. 

Tuberculosis , 53 54 55 —Although suppurative sinusitis occurs 
quite frequently in individuals suffering with pulmonary tubercu¬ 
losis, yet only in isolated instances has it been possible to attribute 

51 . Hajek (6), S. 6. 52 . Zarnico (29), S. 609. 53 . Gleitsmann: Tuberculosis of the 

Accessory Sinuses. Laryn., p. 445, 1907. 54 . Neufeld: Tuberculose, Syphilis und Kiefer- 
hohleneiterung. Arch. f. Lary., Bd. 17, S. 215, 1905. 55 . Keckwick: Antral Empyema 

of Tuberculous Order. Brit. Journ. of Dental Science, p. 433, 1895. 



40 


THE ACCESSORY SINUSES OF THE NOSE. 


the sinus condition to the tubercle bacillus/ Primary infection 
of the sinus mucosa was apparently an unheard-of condition 
until Keckwick reported a case in the maxillary sinus, in which, 
however, the element of doubt was not entirely removed. When 
tuberculosis attacks the sinuses it is through the medium of the 
bone and extends by contiguity to the mucosa of the neighboring 
sinus. Infection through the ostium seems almost never to occur. 
Nevertheless that this is possible, and it is not necessary for an in¬ 
dividual to have tuberculosis elsewhere, is shown by the case re¬ 
ported by Schech, 55a where a woman contracted tubercular sinus 
infection from using a handkerchief belonging to her husband, who 
was a consumptive. All of the sinuses have been reported affected, 
the frontal ethmoid, 55b sphenoid, 550 and maxillary. Tuberculosis of 
the maxillary antrum, however, occurs more frequently than all of 
the other sinuses combined. 

Osteomyelitis, syphilis, and breaking-down of malignant neo¬ 
plasms have also been reported as producing sinus disease. 56-57 
With these diseases the sinus affection is nearly always secondary, 
being due to the caries and necrosis of the osseous walls. The 
primary disease usually occurs outside of the cavity, working its 
way inward; therefore, attention must have been called to it before 
affection of the accessory cavity existed. 

Hajek 57a does not believe that a genuine syphilitic infection of 
the sinus mucosa that is not of a gummous character has ever been 
positively demonstrated. 

Gerber 58 believes syphilitic infections of the sinuses can occur 
in the following manner: a. Through continuity, b. Through 
entrance of syphilitic secretions; and c. Through the blood and 
lymph. As a matter of practical importance, specific infections 
of the sinuses must be rare, despite this author’s statement that 
ten to fifteen per cent, of all syphilitics have specific sinusitis. 

Should doubt exist as to the diagnosis, the Wassermann test 
is to be applied. 

Syphilis.in the third stage shows a marked predilection to 

55a. Schech: Quoted by Dorner (55b). 55b. Dorner: Ueber Tuberkulose der Nasen- 
nebenhohlen. Archiv: fur Laryng., Bd. 27, S. 446, 1913. 55c. Kernan: A case of Tubercu¬ 

losis of the Sphenoid Sinus. Laryngoscope. May, 1919. 55c=l. Kurzak: Die Tuberkulose 
des Keilbeins und ihre Beziehungen zur Hypophyse— Zeitschr. fur Tuberkulose Bd. 34, 
H. 6, 1921. 55d. Cocks: Tuberculosis of Maxillary Antrum, with Presence of Tubercle 

Bacillus in Washings. Laryngoscope, p. 766 1914. 56. Kuttner: Die Syphilis der Neben- 

hohlen der Nase. Arch. f. Lary., Bd. 24, S. 266, 1911. 57. Harke: Beitrag. z. Pathol, u. 

Therap. d. Oberen Athmungswege, 1895, S. 144. 57a. Hajek: Lehrbuch, IV Auflage, S. 10. 

58. Gerber: Die Syphilis d. Nase u. d. Halses, 1895. 

*In 51 phthisical corpses examined on the section table no tubercular inflammation or 
ulceration of the nasal or sinus mucosa was present, although (25) 49 per cent, showed 
accessory sinus disease. (Oppikofer, A. f. L., Bd. xix, 1907.) 



GENERAL CONSIDERATIONS. 


41 


attack the nose, particularly the osseous septum. If prompt treat¬ 
ment is not instituted the disease will often embrace the ethmoid 
capsule and encroach upon the lateral nasal wall, causing exten¬ 
sive necrosis of these structures. 

3. Through the Blood and Lymph-channels. 

This mode of infection is not entirely proved beyond all objec¬ 
tion. While several observers have noted purulent sinusitis asso¬ 
ciated with systemic diseases such as typhoid fever, 57 chronic 
nephritis, 26 cirrhosis of liver, 37 etc., there is nothing to prove that 
it was in any way dependent upon the primary general affection. 
As a matter of fact, under the same circumstances, any severe 
constitutional disease would have produced like results. 

4. Through Traumatism. 59 

Direct injuries usually affect the more superficial sinuses 
(frontal and maxillary), but numerous cases have been reported 
in which the ethmoid has suffered injury, either by the way of the 
nose or orbit, which resulted in secondary empyema. The 
sphenoid sinus, in spite of its depth of situation and protection, 
has also been the recipient of traumatic empyema in several re¬ 
ported cases. In milder cases without actual penetration, blood 
exudes into the sinus from the injured mucous membrane. The 
resisting powers of the sinus being now greatly lowered, a second¬ 
ary infection is the result of the attacks of the inspired germs, with 
the ultimate production of true inflammatory changes, formation 
of pus, and, finally, empyema. 

Experiences in the war zone were in accord with the above 
statements. The maxillary sinuses were injured even more than the 
frontal, totalling about seventy-five per cent, of all cases. This is 
probably explained by the fact that the steel helmets protected the 
frontal sinuses. The frontal, ethmoid and even sphenoid sinuses 
constituted the other twenty-five per cent. These were mostly the 
result of shrapnel and high explosive and frequently entered 
through the cheek and sub-maxillary region. Unless there was wide¬ 
spread destruction of surrounding tissue these recovered on re¬ 
moval of the missile and application of a 10 per cent, iodine solution. 

5. Through Foreign Bodies. 

Empyema of the sinuses through the introduction of foreign 
bodies is not so rare as is generally supposed. This may occur 
by the hand of the physician, i.e., tampons, broken sounds, etc. 60 


59. Ropke: Die Verletzungen der Nase und deren Nebenhohlen. Wiesbaden, 1905. 




42 THE ACCESSORY SINUSES OF THE NOSE. 


Such an accident occurred in the practice of the author. After a Cooper opera¬ 
tion on the maxillary sinus, the patient had been treated a number of times and all 
suppuration had ceased. One day, while cleansing the wound with a cotton pledget, 
it slipped off the carrier and was lost in the sinus. The following day the patient had 
a profuse purulent discharge from the antrum, which continued for several days. I 
had about decided upon a radical operation, when fortunately, during irrigation, the 
cotton was expelled through the ostium with the outflowing solution. Betz 01 reports 
a case of sphenoid empyema in an officer which was caused by a short piece of straw 
penetrating the sinus during a cavalry charge. Foreign bodies may, however, re¬ 
main for years innocuous in a sinus, as has been mentioned by Moore. 62 

A curious case has recently been reported of a snare wire in the ethmoidal 
bulla "which had 02a been in position for three years and had caused a maxillary 
sinusitis accompanied by severe headaches. After a radical operation on the 
antrum, the headache did not subside. An X-ray showed the snare wire in the 
ethmoidal region which, after opening the bulla, was easily removed with im¬ 
mediate cessation of the headache. 

Chiari 63 reports a most remarkable case of a man who, in attempting suicide, 
shot himself through the right temple with a revolver. The wound was situated at a 
level with the eye and about one inch posterior to the external orbital rim. Examina¬ 
tion by the X-ray showed the location of the ball to be in the right sphenoidal sinus. 
Twenty-five days after the reception of the "wound the ball was removed from the 
sinus by the intranasal operation, with complete recovery to the patient. 

Gastric contents forced into the sinuses through vomiting, and 
causing sinusitis, must be classed under foreign bodies. 28 That 
such a condition can occur has been shown by Harke 64 and Wert- 
lieim 28 although their cases were only discovered on the autopsy 
table. Lack, 62 however, reports a patient who was subject to attacks 
of acute antral sinusitis, which were always due to pieces of food 
that had found their way into the sinus. 

Oppikofer, 60 in a post-mortem examination of 200 sinuses, demonstrated the 
presence of gastric contents in 16 cases, or 8 per cent. The total number of 
sinuses, however, which contained this matter was 44; in only 19 was the mucous 
membrane in any way irritated. This would seem the condition occurred post mortem. 

60. Krebs (Foreign Bodies in the Nasal Cavity as a Cause of Empyema, Archives of 
Otology, p. 226, 1908) reports two cases of maxillary empyema caused bv foreign bodies in 
the nasal cavity. 61. Betz: EinFall von Fremdkorper in der Keilbeinhohle. Verh. d. Ver. 
Sfiddeutsch. Lary., S. 13,1894. 62. Moore: Foreign body in right maxillary antrum for twenty- 
five years, causing facial neuralgia, discovered by X-rays and removed by operation through 
canine fossa, with some remarks on foreign bodies in the maxillary antrum. Journal of the 
Laryngology, p. 386, Dec. 1917. 62a. Schlemmer: Schlingendraht (Krauseschlinge), drei Jahre 
im mittleren Nasengang links verkeilt. Chronisches Empyem der Kieferhohle; Eroffnung 
der Bulla; Fremdkorperextraktion. Heilung. Cent, fur Laryng. S. 348, 1921. 63. Chiari: 

Extraction d’Une Balle du Sinus Sphenoidal par voie Endonasale. Arch. Internat. de Laryng., 
T. 31, No. 2, 1911. 64. Harke (57), S. 15. 65. Lambert Lack: Diseases of the Nose and 

its Accessory Sinuses, p. 285, 1906, London. 66. Oppikofer: Beitrage zur Normalen und 
pathologischen Anatomie der Nase und ihrer Nebenhohlen. Arch. f. Lary., Bd. 19, S. 28 1907. 
67* Grtinwald: Beitr. z. chirurgie der oberen Luftwege und Adnexa, Munch, med. Wochen- 
schr., S. 699, 1891. 68. Grtinwald (die klinische Bedeutung der Derivate des Hiatus Sem¬ 

ilunaris, Arch. f. Laryn., Bd. 23, S. 183, 1910) has taken up this subject in detail, and shows 
how, under different anatomical formations, this sinus may or may not receive secretion from 
overlying structures. 69. Killian: Meine Erfahrungen fiber des Kieferhohleneiterungen. 
Munch, med. Wochenschr., No. 4, 1892. 




GENERAL CONSIDERATIONS 


43 


6. Through Contamination by the Pus from an Overlying 
Sinus. 67 Sinusitis e Sinuitide (Killian 69 ). 

That the maxillary sinus often acts as a reservoir for purulent 
secretion which comes from the frontal is a well-established fact, 
and its occurrence depends upon the anatomic configuration of 
the uncinate process and semilunaris hiatus. 68 (See Anatomy.) 
Hajek 6 is also of the opinion that in certain positions of the head 
the sphenoid can receive pus which has been secreted by the poste¬ 
rior ethmoid cells, and vice versa. The experience of the author, 
together with that of many others, has substantiated this in the 
first instance. That this pus will ultimately set up an inflam¬ 
mation in the receiving sinus is also possible, but in the majority 
of cases the induced inflammation is so slight that one or two 
lavages will affect a cure. This fact I have been able to demon¬ 
strate to my own satisfaction time and time again; therefore, it 
would seem that the secondary or receiving sinus possesses more 
or less power to retain the inflammatory products which have 
been secreted by other membranes without itself becoming 
seriously affected. 

In reviewing the aetiological factors it is difficult, and even 
impossible, to state definitely thus and so has been the cause of 
a certain sinus affection. We do not know that all these circum¬ 
stances can contribute toward the existence of the disease either 
singly or combined, but how great a role a certain condition played, 
and how small another, must be, for the present at least, largely a 
matter of conjecture. 


CAUSE OF CHRONICITY. 

As before mentioned, the sinuses exhibit a marked tendency 
toward resolution after having become infected; however in a 
certain number of cases the infection overcomes this tendency and 
the disease becomes chronic. This may be due to a number of 
conditions, the following of which are the most important: • 

1. Interference with normal drainage (congenital or acquired). 
2. Especial virulence of the infecting micro-organisms. 3. Inflam¬ 
matory changes occurring in the mucous membrane. 4. Recur¬ 
rence of the attacks. 5. Continuation of the irritation. 6. 
Consistency of the secretion. 7. Individual susceptibility of the 
patient. 8. Secretion flowing in from another sinus. 


44 


THE ACCESSORY SINUSES OF THE NOSE. 


1. INTERFERENCE WITH NORMAL DRAINAGE. 70 

Congenital .—Under this heading may be placed variations in 
situation and size of ostia, high deviations of the septum, close 
approximation of the middle turbinate to the lateral nasal wall, 
enlarged ethmoidal bulla, or, in fact, any anatomical condition 
which predisposes to interference with drainage. 

Acquired .—The acquired conditions (except traumatic) are usu- ' 
ally confined to the mucous membrane. Among these are classed 
active and passive hypergemias, polypoid swellings, hypertrophies, 
etc. In the majority of these cases, both the congenital and acquired 
predispositions are associated in the causation of the disease. 

When empyema is present in these conditions, there results, 
naturally, more or less obstruction to the outflow of the secretion. 
This pressure of the pent-back secretion, according to Dmochow- 
ski, 27 is the exciting cause of the permanent tissue changes in the 
mucous membrane, with the resulting chronicity. 

2. ESPECIAL VIRULENCE OF THE INFECTING MICRO-ORGANISM. 

Why individuals exposed to precisely the same contamination 
will exhibit totally different reactions is a matter that will yet 
bear considerable explanation. So far as the sinuses are con¬ 
cerned, the idiosyncrasy of the individual probably depends 
largely upon the favorable or unfavorable drainage possibilities 
of the sinus, as well as upon the virulence of the attacking germ 
or the personal susceptibility of the patient. 

3. INFLAMMATORY CHANGES IN THE MUCOUS MEMBRANE OF THE SINUS. 

Killian 44 is especially favorable to this cause, giving, however, 
no definite grounds for his belief except that cedematous swellings 
show but slight tendencies to spontaneous regeneration. 

Killian also rather discredits the theory that the unfavorable situation and 
size of the sinus ostium have any particular influence on the course of the disease, 
and says if this were true it would be impossible to understand the spontaneous 
healing of an acute sinusitis. 

4. RECURRENCE OF THE ATTACKS. 

Under this heading we understand that the patient has been 
subject to recurring attacks with intervening periods of health, 
but, as a consequence of these repeated attacks, permanent inflam¬ 
matory changes resulted in the mucous membrane. In these cases 
complete regeneration of the mucous membrane after a given 
attack did occur. Certain inflammatory changes followed each 
recurrence until chronicity was established. 

70. These conditions have been thoroughly discussed in a most satisfactory article by 
Ballenger, “.Etiology of Inflammatory Diseases of Nose and Accessory Sinuses.” Laryn¬ 
goscope, p. 181, 1997. 




GENERAL CONSIDERATIONS. 45 

5. CONTINUATION OF THE IRRITATION. 

An empyema may be entirely healed and yet an inflammation 
of the sinus mucous membrane still exist, as it is possible for a 
sinus to be inflamed without any trace of exudate being thrown 
off. Chiari 50 believes that a certain amount of the secretion may 
remain in the sinus after inflammation has subsided and continue 
to irritate the mucosa, thus giving rise to hypertrophic and cystic 
degeneration, with permanent glandular changes. In this manner 
the sinus inflammation may continue long after the nasal inflam¬ 
mation has disappeared and finally take on the form of chronic 
purulent catarrh. 

6. THE CONSISTENCY OF THE SECRETION. 

The consistency of the secretion can also play an important 
part in the chronicity of the disease. It follows reason that the 
thicker the secretion, the more difficult is the establishment of 
drainage. • 

7. THE INDIVIDUAL SUSCEPTIBILITY OF THE PATIENT. 

8. SECRETION FLOWING IN FROM ANOTHER SINUS. 

As has been elsewhere mentioned, this condition is noted par¬ 
ticularly in the maxillary sinus, but can possibly occur also in the 
posterior ethmoid and sphenoid. It does not always follow, 
though, that the receiving sinus itself becomes affected, as it is 
possible for it to act merely in the capacity of a reservoir for an 
undetermined length of time. Whether or not infection ultimately 
occurs depends upon the above-mentioned factors. 

Zarnico 71 differentiates two conditions when dealing with this subject: 1. When 
the underlying sinus acts as a reservoir and does not become affected—pyosinus. 
2. When the underlying sinus acts as a reservoir and ultimately becomes infected— 
sinusitis e sinuitide. 

When reviewing these various conditions which predispose to 
chronicity it would seem to be impossible to state with certainty 
in each individual case that particular factor which has been the 
cause of the disease bcoming chronic. When one takes into con¬ 
sideration that the line of demarcation between the acute and 
chronic stadia is exceedingly variable (the time being variously 


71. Zarnico (29), S. 610. 



46 


THE ACCESSORY SINUSES OF THE NOSE. 

given at from four to ten weeks), it must necessarily follow that 
the pathogenic processes operating within the sinuses must vary 
in manner, degree and intensity; therefore the occurrence of 
chronicity would depend more upon certain combinations of the 
above conditions than upon one individual tendency. 

Statistics. 

The postmorten observations from various clinics would seem to show that 
sinus disease is much more prevalent than formerly supposed. Examinations made 
in the autopsy room of all cases, regardless of the cause of death, give varying 
percentages in which the sinuses were found affected. Thus Gradenigo 72 found sinus 
suppuration present in forty-five out of two hundred and three examinations, or 
22 per cent.; Harke, 57 one hundred and thirty-eight out of four hundred, or 34.5 
per cent.; Frankel, 26 sixty-three out of one hundred and forty-six, or 43.1 per 
cent.; Lapalle, 73 fifty-five out of one hundred and sixty-nine, or 32 per cent.; 
Wertheim, 28 ninety-five out of three hundred and sixty, or 26 per cent.; Minder, 74 
fourteen out of fifty, or 28 per cent.; Kirkland, 75 thirty-five out of one hundred, 
or thirty-five per cent.; Torne, 24 fourteen out of seventy-three, or 17 per cent.; and 
Oppikofer, 66 ninety-four out of two hundred, or 47 per cent. It was found in 
those cases of pneumonia and influenza the percentage rate ran high above these 
figures. In ninety-two cases of influenza coming to autopsy, it was found that 
in seventy-one the mucosa of the sphenoid sinus showed distinct signs of infection. 
Generally speaking, sinus disease was most prevalent in conditions associated with 
inflammation of the respiratory system. 

Comparing these statistics with those of clinical experience, it will be noted 
that there exists a marked discrepency—Chiari, for example, gives two per cent, 
as the total proportion of sinus disease occurring in his clinic in five years, which, 
in view of the refined technique of the present, is probably a trifle low. Under 
the best circumstances, however, it is impossible to reconcile the wide disproportion 
in the figures without an adequate explanation. Torne, 22 by his observations and 
experiments on the living ciliary epithelium of animal sinuses, has gone far to 
elucidate this problem. 

Having shown that the cilia not only are capable of but actually do remove 
extrinsic substances* from the sinuses by way of the ostium, it stands to reason 
that anything interfering with ciliary motion would predispose to the accumulation 
of material within the cavity. The sinuses contain mucoid glands which con¬ 
tinually secrete, the secretion being taken up both by the nose and by evaporation 
in the sinus. During the last hours of the individual the cilia may become 
enfeebled and cease to perform their function. In this manner we can readily 
have a postmortem accumulation of secretion in the sinuses. Lack 76 has also 
accepted this theory, and calls attention to the fact that the only true criteria of 
sinus inflammation are definite pathological changes in the sinus mucosa. The mere 
presence of serous or mucoid fluid may be the result of a slight catarrh or even 
postmortem seepages from the nose through the ostium. That body fluids can 
readily find their way into the sinuses after death is a matter too well recognized 
to deserve further comment. 

72. Gradenigo: Sur l’Empyeme Latentdu Sinus Maxillaire. Ann. d. Mai. de Torielle, 
No. 20, p. 451, 1894. 73. Lapaile: Tableau statistique de 169 autopsies de sinus de la face, 

Arch, internat. de Laryn., T. 12, p. 225,1899. 74. Minder: 50 Sections befund d. Nase und 

deren Nebenhohlen, etc. Arch. f. Lary., Bd. 12, S. 328, 1902. 75. Kirkland: The Patho¬ 
logical Conditions of the Cranial Sinuses. Journ. of Lary., vol. 17, Nov., 1902. 75a. Prym: 

Erkrankungen der Nasennebenhohlen bei Influenza. Deutsch. Med. Wochens, No. 32, 
S. 880,1919. 76. Lack (65), p. 268. 





GENERAL CONSIDERATIONS. 


47 


PATHOLOGICAL CHANGES IN THE MUCOUS MEMBRANE OF THE 

SINUSES. 

Before taking these changes np in detail it might be well to 
briefly review the normal histology. The normal histology of the 
lining membrane of the sinuses is, to all intents and purposes, 
one and the same; i.e., the microscopic appearance of the antral 
mucous membrane is practically identical with that of the sphenoid 
or frontal sinus; the ethmoid cells present some slight difference, 
chiefly on account of their structural peculiarities. (See Path¬ 
ology of Ethmoid Labyrinth.) 

A cross-section of the mucous membrane of the maxillary 
sinus, together with the bone, will show, under the low power of 
the microscope, the following structures (Plate 2a) : The epithe¬ 
lium is composed of the ciliated variety similar to that found in 
the respiratory portion of the nose (basement layer). Sub-epi¬ 
thelial layer contains the blood-vessels and the glands, the latter 
occurring as isolated clusters scattered here and there. This 
layer is so intimately associated with the periosteum that it is not 
possible to distinguish a dividing line. These tracts resemble those 
of the respiratory surface, but may be distinguished by the scarcity 
of glandular tissue and the marked reduction in the thickness of 
the mucous membrane, which in these spaces is seldom more than 
.02 mm. 

The pathological changes which take place in the course of the 
purulent inflammation depend upon several conditions: 

1. The length of time the disease has progressed. 

2. Virulence of the attacking germ or germs. 

3. Resistance the sinus has shown toward the disease. 

4. Favorable or unfavorable drainage conditions. 

The maxillary sinus usually shows the greatest pathological 
changes. This is due to the unfavorable situation of the ostium 
for drainage; as a consequence, the mucous membrane at the infe¬ 
rior portion is constantly bathed in the purulent secretion. This, 
I think, accounts for the fact that cheesy, fetid pus is so frequently 
observed in old chronic empyemas of this sinus, regardless of their 
primary origin. 

These conditions are so intimately associated and intermingled 
that it is impossible to differentiate them, at least so far as the 
microscope is concerned; therefore, they had best be con¬ 
sidered under the more general heading: Acute and Chronic. 


48 


THE ACCESSORY SINUSES OF THE NOSE. 


When the mucous membrane becomes first infected, there re¬ 
sults an intense hypersemia and swelling, due to the outpouring of 
serum into the submucous connective tissue layer, which may be 
so great as to occlude the lumen of the sinus. The swelling en¬ 
croaches more and more on the cilia, causing them to wave more 
and more slowly until, if the pressure is sufficient, they cease alto¬ 
gether. During this stage no secretion is formed, because the 
lining membrane has not been penetrated by the exudate. This 
stadium is followed by oedema, caused by the pressure on the 
blood-vessels. 

Blood-vessels: The vessels which supply the sinuses enter through the ostia 
and return by the same route, with the exception of small, unimportant branches 
which pierce the bony walls. On this account pressure in a given portion of the 
sinus will cause circumscribed oedema directly back of that particular portion. 
This fact accounts for the circumscribed swellings and cyst formation often 
found in the maxillary sinus. 

As the cilia have become motionless, the mucosa is no longer 
able to throw off the secretion which is continually forming within 
glands and, by osmosis, through the epithelium, in the event of 
inflammation. This inflammatory exudate is composed of serum, 
mucus, leucocytes, and exfoliated epithelium. Micro-organisms 
may or may not be present. The exudation in the beginning is 
scanty, becoming serous or serous-bloody, depending upon the 
infection. 

Resolution may now set in with gradual reduction of the hyper- 
aemic and oedematous swellings, the cilia again being set in motion, 
and the secretion either ceases entirely or assumes a mucoid, 
or serous muco-purulent and finally a watery character with resti¬ 
tutio ad integrum . If, however, the inflammation continues and 
micro-organisms find their way into the cavity, the cilia being over¬ 
powered by the swelling and secretion, they may find suitable soil 
for their propagation in the areas where punctiform hemorrhages 
and areas of desquamation of the epithelium have occurred. 

The formation of a false or diphtheritic membrane in the acute stadium has been 
observed. 26 ’ 27 

THE MICROSCOPIC APPEARANCE OF THE MUCOUS MEMBRANE IN ACUTE 

CONDITIONS. 

The epithelium is unchanged; mucous membrane, oedematous; 
intracellular spaces filled with lymph; more or less round-cell in¬ 
filtration, depending upon the degree of irritation; punctiform 


GENERAL CONSIDERATIONS. 


49 


hemorrhage through connective tissue; blood-vessels engorged; 
glands unchanged. 

If, however, from any cause, the pathological process continues 
with damming hack of the secretion, the inflammatory symptoms 
become more marked. Greater changes, such as round-cell infil¬ 
tration, petechial hemorrhages and desquamation, occur in the 
mucosa. The round-cell infiltration penetrates the deeper layers 
until the bone is reached, causing pressure, with subsequent 
tendency toward ulceration caries. Complete resolution cannot 
occur after this stage of inflammation, for the destruction has been 
so extensive as to preclude the possibility of Nature overcoming 
these pathological changes. The mucosa is thickened from the 
overgrowth of fibrous connective tissue. The lining epithelium, 
having lost its cilia, is metamorphosed into the squamous or pave¬ 
ment variety. The glands are, for the most part, destroyed and 
the blood-supply greatly diminished by the obliteration of the finer 
arterioles and veinlets. If restitution does not occur in a given 
length of time (four to ten weeks), the disease may be said to have 
become chronic. 

No given length of time can be arbitrarily stated in which an acute disease 
will become chronic. It depends entirely upon the numerous causes and com¬ 
binations of causes which have given origin to the disease, together with the 
favorable or unfavorable anatomic configurations, not to mention the virulence 
of the attacking micro-organisms or the susceptibility of the individual. There 
exists no sharp line of deviation, either clinically or pathologically, between the 
acute and chronic stadiums. Oppikofer calls attention to the fact that even in 
autopsy findings it is difficult to determine whether the diseased sinus was acutely 
or chronically affected. 

Chronic sinus inflammation exhibits two distinct types: 
(1) hyperplastic; (2) ulcerative. These forms are not entirely 
disassociated, as transitional stages are found in the same sinus. 

1. Hyperplastic Type.— The mucous membrane is of a grayish 
color, often wrinkled and papillomatous and more or less loose 
from the underlying bone. Hyperaemia, while present, is not so 
marked as in the acute inflammation. (Edematous changes occur 
in the mucous membrane which are similar to the ordinary nasal 
polyp. The connective tissue is thickened. (New formation.) 
Retention cysts often occur from constriction of the necks of the 
glands, due not only to the pressure from the round-cell infiltration 
but to the formation of connective tissue, as the glands and vessels 
may be atrophied or vessels may be numerous and more or less 


4 


50 


THE ACCESSORY SINUSES OF THE NOSE. 


dilated. (These two conditions frequently occur in the same speci¬ 
men.) (Plate 2.) 

Small areas of metamorphosis of ciliated into pavement epi¬ 
thelium. Round-cell infiltration usually marked, but may fail en¬ 
tirely. Pavement layer hypertrophied and prominent, taking well 
eosine stain. Connective tissue thickened, vessels numerous and 
more or less dilated. 77 Osteoblasts frequently found, osteoclasts 
seldom. This is due to the positive disturbance of nutrition 
(venous stasis). No micro-organisms have as yet been found in 
the sinus mucosa. 


Differential Diagnosis. 


Acute. 

Epithelium unchanged. 

Never found. 

Not visible. 

Connective tissue spaces widened. 
Lymphocytes few. 

Not common. 

Punctiform hemorrhages large. 
Bone seldom affected. 


Chronic. 

Epithelium higher. 

Pavement epithelium frequently found. 
Base membrane thickened. 

Connective tissue thickened. 
Lymphocytes many. 

Fold formation common. 

Punctiform hemorrhages small. 

Bone often affected. 


2. Ulcerative Type.— No specimen has come under the author’s 
observation where the ulceration was the predominating feature. 
The true ulcerative type is probably not found as such, but is 
rather a hyperplastic condition associated with ulcerosus. The 
relative extent of this pathologic process (ulcerosus) depends as 
much upon the pressure upon the mucosa as upon the action of 
excessively virulent micro-organisms. 

1. Unusual Pathological Complications or Sequels of 
Chronic Inflammation: New Formation and Ulceration of 
Bone, Caries and Necrosis.— Recollecting that the third layer of 
the mucosa and the periosteum are intimately blended, it is easy 
to see why the bone so often becomes affected during the course of 
a severe sinus inflammation. Were it not for the collateral circu¬ 
lation through the sinus walls this would happen with much greater 
frequency. 

New Bone Formation .—When the inflammation first meets the 
periosteum the blood-vessels supplying the osteoblasts become 
dilated. If the irritation does not progress beyond this point, on 


77. Oppikofer (Arch. f. Lary., Bd. 21, S. 422) found this condition in about 40 per cent, 
of cases examined. It was never found in the acute type, therefore where found is indica¬ 
tive of chronic disease. 



PLATE 2, 



A, Normal mucosa of ethmoid. 



B, Acute inflammation. 


Thickening of mucosa. 


Intense round-cell infiltration. 


Blood-vessels dilated. 



C, Chronic inflammation. 


Metamorphosis of ciliated epithelium into columnar. New formation of 
fibrous tissue. 
















GENERAL CONSIDERATIONS. 51 

account of the excessive nutrition brought to the part, new bone 
is deposited in an irregular fashion on the internal walls of the 
sinus, giving it a roughened appearance. This has no patho¬ 
logical significance. 

Ulceration of the Bone .—This condition seems to be dependent 
npon an especially virulent infection, being always accompanied 
by ulceration of the superimposed mucosa. It is observed par¬ 
ticularly m those cases where partial or complete stagnation has 
been present; therefore, it would also seem that the pressure of 
the secretion contributed largely in the aetiology of the ulceration. 

Caries and Necrosis .—Actual destruction of a portion of the 
osseous wall is relatively rare. Gerber 78 has collected three 
hundred and nineteen cases, and asserts that this complication is 
always due to infection through the circulatory system. 

2. Dilatation of Sinus by Internal Pressure of Secretion 
(Mucocele, Pyocele, and Latent Empyema). —That a simple 
empyema, either acute or chronic, would cause actual displacement 
of the sinus walls has, until recent years, been a controvertible 
theory. Hajek formerly championed the negative view 79 in no 
uncertain manner, until he was able to prove to his own satisfaction 
the existence of such a condition in the ethmoid labyrinth of one 
of his own patients. 80 

It is conceivable bow pressure from the contained secretion could cause bulg¬ 
ing of the wall of the ethmoid and maxillary (nasal wall), as these are exceedingly 
thin, but that the anterior wall of the frontal sinus should give way under these 
conditions seems almost incredible, at least from an anatomical point of view. 
(See Anatomy of Frontal Sinus.) Gerber, 78 however, insists that such is the 
case, and claims to have observed the condition on many occasions. 

Mucocele . 81 ’ 82 —This condition is due to a collection of mucous 
secretion within a sinus, resulting from obstruction to its outlet, 
with ultimate distention of the walls of the cavity. The sinuses 
most frequently affected are the frontal and anterior ethmoid 
cells. Mucocele of the sphenoid sinus rarely seems to occur. 

The aetiology of these mucoid accumulations is not entirely 
clear, but it suffices to say that as the ostium of the affected! sinus 
has been gradually occluded by chronic catarrhal inflammation; 

78. Gerber: Komplicationen der Stirnhohlenentziindungen. S. 32, Berlin, 1909. 
79. Hajek: Discussion zu Gerbers Vortrag. Die Komplicationen der Stirnhohlenentziin- 
dungen. Deutsch. Lary. Gesell. zu Dresden, 1907. 80. Hajek: Acute empyern d. 
Siebbeinlabyrinth, etc. Zeitschr. f. Lary., Bd. 1, p. 629, 1909. 81. Logan Turner: 
Mucocele of the Accessory Nasal Sinuses. Edinburgh Med. Journ., Nov. and Dec., 1907. 
82. Hastings: Mucocele of the Nasal Accessory Sinuses, etc. Ann. Otol., Rhin. and 
Lary., Sept., 1911. 



52 THE ACCESSORY SINUSES OF THE NOSE 

the glands of the sinus mucosa continuing to secrete, the end 
result must be a gradual displacement of the walls, with ulti- 
mate rupture. 

The cause of this occlusion has been attributed to several 
processes. 

1. Traumatism to the wall of the sinus, followed by a low grade 
of periostitis which gradually invades the sinus cavity and, by 
plastic inflammatory swelling, closes the ostium. 

2. Cyst formation in the sinus mucosa, the glands continuing to 
secrete until the cyst completely fills the sinus cavity. 

3. A closed empyema in which the causative micro-organism 
has lost its virulence and the purulent secretion has undergone 
mucoid changes. 

4. Extension of a local inflammation from a neighboring part 
affecting the mucosa around the ostium of the sinus, the resulting 
swelling and plastic inflammation causing it to close and adhere. 

It must be remembered that the sinus mucosa can also absorb 
fluids which may account for the occasional spontaneous cessation 
of growth of a mucocele. 

On account of the slow course taken, pain is rarely felt in the 
early stages of the disease, and it is not until distinct bulging * of the 
external walls is noted that the patient comes under medical aid. 

If the mass is allowed to accumulate, considerable deformity, 
particularly from the stand-point of the orbit, will occur, and 
irreparable damage will be done to the eye on the affected side. 
(See Frontal Sinus and Ethmoid Labyrinth.) If by any chance a 
mucocele becomes infected, a pyocele immediately results, chang¬ 
ing the process from an ultrachronic one to one of acuteness, 
depending upon the virulence of the infective micro-organism. 

3. Metamorphosis of the Secretion into a Cheesy Mass (Ver- 
kasung 83 ). —A condition occurring during the course of a sinus¬ 
itis, being due to the regenerative ability of the sinus mucosa, as 
well as the worn-out virulence of the infecting micro-organism. 
The inflamed mucous membrane recovers little by little until it is 
able to successfully withstand the attacks of the micro-organism. 
The contained secretion, not being able to escape, becomes stag¬ 
nated, loses its moisture, and a fatty degeneration of the pus 
corpuscles results. After a time this mass becomes more or less 

*These dilatations have been known to accumulate for ten to twenty years. 

83. Avellis: Der Ausgang des acuten Kieferhohlenempyems in Verkasung, etc. Arch, 
f. Lary., Bd. x, S. 271, 1900. 



GENERAL CONSIDERATIONS 


53 


solid, with certain characteristics of soft cheese. As the only 
irritation present is from the action of the mass itself upon the 
sinus mucosa, no pus is present; only a thin, sourish secretion is 
found. (See Maxillary Sinus.) 

4. Cholesteatoma Formation. 84 — This may be due to two inde¬ 
pendent causes. 1. The disturbance in evolution during embryonic 
life (true cholesteatoma). 2. Encroachment of the epithelium from 
without into the sinus cavity (false cholesteatoma). The true 
cholesteatoma exists from birth and is probably a factor in the 
causation of the subsequent empyema. The false cholesteatoma 
is always dependent upon, and the product of, the existing sinus 
suppuration. (See Maxillary Sinus.) 

5. Calcareous Formation.— Stone formation in the sinus is 
very rare, barely a dozen cases being reported. It shows prefer¬ 
ence for the maxillary sinus, as the majority of examples have been 
found in this cavity. See Maxillary Sinus.) No especial cause 
has been attributed to their formation. 

6. Carcinoma.— Malignant tumors of the sinuses are not as 
common as is generally supposed, the one most frequently met with 
being carcinoma. 85 Any of these may excite a true purulent sinus¬ 
itis through breaking down and ulceration of the mucosa. 86 The 
tumor itself remains usually unrecognized until tumefaction sets in. 

Relative Importance of the Secretion in Chronic Empyema. 

Absolutely no reliance can be placed upon the character of the 
secretion as an indication of the pathological condition of the 
sinus mucosa. It may be profuse, foetid, and of a greenish color, 
yet the mucosa shows but few, and even insignificant, pathological 
changes, and, again, it can be thin, serous, and scanty, yet the 
entire sinus will be filled with hyperplastic and cystic degenerated 
mucous membrane. 87 These apparently anamalous conditions are 
explained by the kind and virulence of the infection, for it appears 
that the infecting organisms act principally on the epithelium and 
do not penetrate into the depths of the mucosa. 

Hajek says the secretion is acute and chronic inflammation can be differentiated 
by the fact that the pus in acute inflammation appears to mix with the injected fluid, 
while in chronic empyema the secretion shows a great tendency to segregate 
into masses. 

84. Heimendinger: Beitrage z. Path. Anatomie der Kieferhohle. Arch. f. Lary., Bd 
xix, S. 382, 1907. 85. Citelli: Tumeurs Primitives des Sinus du Nez. Archiv. Internat. de 

Laryn., T. xxv, p. 1, 1908. 86. Manasse: Zrr Pathol. Anatomie und Klinik der Malignen 

Nebenhohlengeschwiilste. Zeitschr. f Laryn., Bd. 1, S. 517, 1909. 87. V. Eicken: Disto 

Tilley. A case in which no pus was to be seen in the nose at repeated examinations, yet on 
operation both the anterior and posterior walls of the frontal sinus were carious, the dura 
being exposed and covered with granulations. Verh. 1st Internat. Laryng.-Rhin. Congress, 
S. 222, 1908, Wien. 



54 


THE ACCESSORY SINUSES OF THE NOSE. 


As a rule, when the drainage is not good, saphrophytic organ¬ 
isms find entrance into the sinus and cause the secretion to become 
malodorous. If no apparent interference with drainage is present 
and the secretion becomes foetid, it is usually significant of some 
deep-seated tissue involvement. 

LATENT EMPYEMA . 88 

By this term is understood the presence of a well-defined sup¬ 
purative process within a sinus which continues without giving 
rise to appreciable symptoms, and being probably due to infection 
from micro-organisms of slight virulence. This condition is in 
reality a mild catarrhal process, which nevertheless may become 
virulent, and even fatal 89 under the influence of certain forms of 
irritation, by quickening the dormant bacteria or reducing the re¬ 
sisting powers of the sinus mucosa. The diagnosis is difficult, 
but not more so than the mild catarrhal inflammation; care must 
be exercised to differentiate from purulent rhinitis, ulcerating neo¬ 
plasms, and small foreign bodies. Pus formed in the choana (ade¬ 
noids) can appear in the superior nasal passage and olfactory fis¬ 
sure and simulate disease of the posterior ethmoid and sphenoid. 

Symptoms of Sinus Inflammation. 

The symptomatology of this affection is not solely confined 
to the head, therefore it must be divided into local and general. 

LOCALIZED HEADACHE. 

Headache resulting from sinus affections is one of the com¬ 
monest and at the same time least understood of all the symptoms 
associated with the disease. As an individual symptom indicative 
of disease of a particular sinus it is thoroughly unreliable, but 
its presence or absence in the entire symptom-complex is most 
important. Its mere absence proves nothing, while its prepuce 
may be of inestimable value in making a correct diagnosis. That 
many such cases have often gone unrecognized is well shown in 
the following statement by Hajek . 90 When speaking of this sub¬ 
ject, he says: “Many cases of sinus disease with slight nasal 
symptoms go through their entire life with the diagnosis of chronic 
headache, taking all manner of cures, such as electro- and hydro¬ 
therapy, sea baths, general and special (body) massage, without 
it ever occurring to anyone that the headache might be caused by 

88. Shambaugh: The Diagnosis of Latent Frontal Sinusitis. Am Journ. of Med. 
Sciences, vol. 123, p. 416, 1902. 89. Cott: Four Deaths in Latent Sinusitis. Am. 
Journ. of Surgery, vol. 26, p. 116, 1912. 90. Hajek (6), S. 13, 1909. 



GENERAL CONSIDERATIONS. 55 

a structural disease in the immediate neighborhood (accessory 
sinuses of the nose).” It is, of course, presupposed that these 
individuals have never been subject to a thorough rhinoscopic ex¬ 
amination. The explanation why this symptom is so little under¬ 
stood will be better appreciated when one studies the following 
individual peculiarities. 

Cause ——The cause of the headache depends upon one or more 
of several conditions, a. Swelling of the mucosa with pressure 
or irritation of the nerves, b. Direct contact of the swollen mucosa, 
c. Negative pressure in the sinus. 90a d. Stasis following obstruc¬ 
tion of the draining passages, e. Ulceration of mucosa with in¬ 
volvement of the nerves. /. Reabsorption of toxins formed within 
the sinus, g. Any condition which causes active congestion of the 
cranial circulation (acute exacerbation of a chronic inflammation, 
overindulgence in alcohol and tobacco, etc.), h. Disturbances in the 
blood and lymph circulation at the base of skull . 91 

The experience of the author would indicate that pressure on 
the septum from hypertrophies which so often co-exist with sinus 
inflammations is one of the main causes of persistent headache 
associated with this disease. That many of the reported cases in 
which the pain was instantly relieved by the application of cocaine 
and adrenalin to the drainage passages were in reality relieved 
by removing the pressure from the septum seems to be beyond all 
reasonable doubt, as the following case will show: 

E. B., 40 years, consulted me for persistent headache, which had troubled him for 
the past two years. Examination and subsequent treatments showed ethmoid hyper¬ 
plasia on the left side which corresponded with the headaches. The mucous mem¬ 
brane of the inferior turbinate of the same side was polypoid degenerated poste¬ 
riorly, encroaching upon the septum. I promised him complete relief after an opera¬ 
tion, which would consist of removal of the diseased ethmoidal cells. He consented, 
and this operation was performed. After several days he reported for examination, 
still complaining of the pain, which apparently had not been influenced by the 
surgical procedure. This, however, I attributed to postoperative swelling. The 
ethmoid wound healed in a few weeks with no recurrence of the polypi, the head¬ 
aches, however, persisting. I suggested that the hypertrophied mucosa of the in¬ 
ferior turbinate be excised. The patient was desperate and readily consented to any¬ 
thing in order to' obtain relief. The mucous membrane was accordingly, excised with 
a spoke shave with, much to my delight, immediate relief from this pain. The head¬ 
ache had not recurred several months after the operation. This case demonstrates 
only too well how, when certain sinus conditions are present which should be ac¬ 
companied by headaches, we are apt to take too much for granted and promise re¬ 
sults which, much to our embarrassment, fail to materialize. 

Lack of Constancy .—In the chronic form of the disease head¬ 
ache is one of the most inconstant symptoms, the violence of the 


90a. Sluder: Vacuum Nasal Headaches with ocular symptoms only. Ann. Otol Rhin. 
and Laryng. March, 1912. 91. Griinwald: Die Lehre von der Naseneiterung, S. 11.4.1896. 



56 THE ACCESSORY SINUSES OF THE NOSE. 

pain having apparently no relation to the severity of the disease. 
In certain cases the pain will be almost unbearable, yet the actual 
symptoms are insignificant; in others the headache is mild, yet 
enormous tissue changes have taken place in the sinus. Holmes 
says we may have purulent inflammation of all the sinuses on both 
sides without the patient ever having suffered from pain at any 
time. The author has never observed such a case. Regarding the 
frequency of pain in sinus inflammation, Griinwald puts it at 100 
per cent, in the acute forms, and 50 per cent, in the chronic. 

Character .—Under this heading 
it must be borne in mind that we have 
mostly to deal with referred pain 
through the various branches of the 
trigeminus nerve. Fig. 30 will illus¬ 
trate how this nerve supplies the 
various sinuses and the numberless 
ramifications of its branches. 

The character of the headache 
varies between the sharp twinging 
of neuralgia 92a and a heavy, full, be¬ 
numbed sensation (benommensein ); 
often the pain is almost indistin¬ 
guishable from ordinary trigeminal 
\ neuralgia. These conditions are fre¬ 
quently associated, the acute neu- 

Fig. 30.—Distribution of the three branch- ^ing f ° ll0Wed ^ a diffUSe 

headache or, more often, by a sense 

Inferior maxillary division. 4. Occipital nerves. weight and fulneSS 

As a general rule, acute inflammation of a sinus is charac¬ 
terized by neuralgic pain in the affected cavity (frontal and max¬ 
illary) ; there may accompany this referred pain through the other 
nerve branches. 

In chronic sinusitis the headache may take on any form, as has 
been noted above; however, one staple characteristic is always 
observed, i.e., diffuse headaches from accessory sinus disease dur¬ 
ing recurrent attacks, cause pain in the same portion of the head. 
Treatment will, of course, influence the character and often the 
localization of this pain. 

92. C. P. Holmes:" Head Pains Caused bv Inflammation of the Accessory Sinuses of 
the Nose. Ohio State Med. .Tourn., Feb., 1906. 92a. Jobson: Trifacial Neuralgia from 
Nasal and Accessory Sinus Disease. Penna. Med. Journ., March, 1915. 





GENERAL CONSIDERATIONS. 


57 


Snow, 83 Roe, 93a and Sluder, ?3b have observed the occurrence of tic douloureux 
associated with sinus disease, especially sphenoiditis. These authors endeavor to 
prove the inflammatory condition of the sinus, the causative factor of the tic. 
Faulkner 93c rejects this theory, stating that he seldom, if ever, found sinus disease 
to be a constant factor. My own experiences would bear out those of Faulkner. 


Periodicity .—In certain cases intervals of complete rest are 
observed between the attacks of pain. Not infrequently headache 
manifests itself at a certain time of the day, lasting a few hours, 
then vanishing as quickly as it appeared, only to return at the 
same time the following day. The pain in these cases usually 
appears in the forenoon and lasts several hours. The term “sun 
pains’’ has often been falsely applied to this condition. In certain 
other cases of chronic sinus disease the patient may be relatively 
free from discomfort for days and even weeks at a time. 

Variations in Intensity .—The head pain is intensified by con¬ 
stipation, straining at stool, stooping, sudden jarring, as jumping 
and lighting upon the heels, also by severe mental work and loss 
of sleep. As before mentioned, the indulgence in indigestible foods 
as well as alcohol and tobacco greatly contributes toward this cause. 

Occasionally the pain and general feeling of distress in the head 
will become so great as to excite suicidal tendencies in the pa¬ 
tient, 69 ’ 94 as the following case will illustrate. 

M. R., 45 years, conductor, presented 1 himself for examination with the history of 
considerable discharge from right side of nose, particularly in the morning, parox¬ 
ysmal headaches, which sometimes became unbearable; constant feeling of fulness 
on right side of face and head. This condition had been present for several months 
and was gradually becoming worse, so that he could no longer sleep. He said that 
he had often been tempted to throw himself from the train, as the constant pressure 
in his head was beginning to affect his mind. Examination showed symptoms 
pointing to maxillary sinus involvement, and on exploratory needle puncture great 
quantities of greenish lumpy, and extremely foetid secretion were washed out, with 
complete and instant relief. The lavages were continued for several weeks and 
ultimately resulted in a cure. 

Localisation —The general impression still seems to prevail 
that inflammations in certain sinuses will invariably cause pain 


93. Snow: Tic Douloureux and other Neuralgias from Intranasal and Accessory Sinus 
Pressures. N. Y. and Phila. Med. Journ., vol. 81, p. 68, 1905 93a. Roe: Tic Donioureux 

from Sphenoidal Disease. Trans. Am. Larvng. Assn, p. 309, 1904. 93b. Sluder: two 

cases of Tic Douloureux of Sphenoidal Inflammatory Etiology. Laryngoscope, p. 122, 
Feb., 1916. 93c. Faulkner: Tic Douloureux with Special Reference to Treatment by 

Alcohol Injections. Laryngoscope, March, 1919. 94. Grunwald,9), S. 112. 95. Kopetsky. 
The Relation of Headache, etc., N. Y. and Phila. Med. Journ., Dec. 2, 1905. 



58 THE ACCESSORY SINUSES OF THE NOSE. 

in definite Localized areas of the head. This is really not the case, 
the exceptions far outnumbering the rule. However, individual 
sinuses seem to show some predilection for causing pain, or, at 
least, some sensatory disturbances in certain defined regions. The 
general idea of this phase of the subject can be obtained from 
Fig. 30, which shows the distribution of the trigeminus and the 
possibilities of referred pain from the sinuses to all parts of the 
face and head. Fig. 31 shows the regions which are more fre¬ 
quently affected from the individual sinuses. Thus, a dull pain 



between the eyes should be significant of ethmoidal disease. This 
is usually accompanied by a sense of weight over the vertex. 

Acute maxillary sinusitis, during some stage of its course, will 
often show neuralgic pain directly in the sinus. In chronic antral 
suppuration, curiously enough, the pain is often limited to the dis¬ 
tribution of the supra-orbital nerve. 96 Chronic frontal sinus in¬ 
flammation is looked upon as the one sinus affection which in¬ 
variably shows some form of pain as one of the necessary symp¬ 
toms. While in the main this is true, nevertheless cases have been 
reported in which severe inflammatory changes in the sinus mucosa 
had occurred, yet the patient had never experienced the -slightest 
discomfort. The pain, when present in this form of the disease, 
is apt to be limited to the supra-orbital region, and in typical cases 

96. Hajek: Kopfschmerz bei Erkrank. der Naseund der Nebenhohlen. Wien.med. 
Presse, No. 11, 1899. 










GENERAL CONSIDERATIONS. 


59 


is remittent in type, sometimes almost indistinguishable from idio¬ 
pathic supra-orbital neuralgia. During the remissions of pain a 
dull, heavy sensation frequently intervenes. 

Inflammations of the sphenoid sinus can give rise to the most 
excruciating pain through the temples, extending into the mastoid 
process and even the middle ear and over the vertex, which, in 
the latter region, changes its character to a sense of heavy weight 
and oppression. This sinus, with the posterior ethmoid cells, also 
causes varying degrees of pain in the occipital region. 

It must not be inferred that the above symptoms are invariable, 
for such is, unfortunately, not the case. An uncomplicated frontal 
sinus disease has been known to give rise to occipital pain, and a 
sphenoidal sinusitis to supra-orbital neuralgia. Generally speak¬ 
ing, however, the above can be considered as a close criterion of 
the various head pains lending themselves to differentiation which 
occur in accessory sinus inflammations. 96a (For further details see 
Special Sinuses.) Yankhauer 97 calls attention to a point in diag¬ 
nosis, in headaches of suspected sinus origin, which has been 
found valuable. Inhalations of steam will shrink the nasal mucosa, 
stimulate ciliary motion, and favor drainage from the sinuses by 
enlarging the passages; therefore, if a patient suffering from a 
chronic recurrent headache makes use of steam inhalations with 
even partial or temporary relief, it can definitely be stated that 
the cause of the headache lies in the nose or one of the nasal acces¬ 
sory sinuses. 

TENDERNESS OVER THE SINUSES. 

This is of value as a diagnostic symptom when present only 
over the frontal sinus, very rarely the maxillary. The point of 
tenderness is not unlimited over the anterior wall, but confined to 
a small area on the floor of the sinus directly above the inner can- 
thus of the eye. 98 This is the point where swelling usually occurs, 
being the thinnest bony portion of the wall, and is often the seat 
of exquisite tenderness. This symptom, when present, is pathog¬ 
nomonic of frontal sinus inflammation, but comparison should 
always be made with the sound side to elicit the distinction, as in 
neurotic individuals false impressions may often be obtained. 

Griinwald 91 has attempted to demonstrate that pressure 
between the eyes will often elicit points of tenderness in ethmoidal 

96a. Tibotson: Headaches of Sinus Origin. Position and Character. Practitioner 
Sept., 1918. 97. Yankhauer: The Drainage Mechanism of the Accessory Sinuses. Laryn¬ 
goscope, p. 518, 1908. 98. Kuhnt: Uber die Entziindliche Erkrankung der Stirnhohle. 

Wiesbaden, 1895. 




60 


THE ACCESSORY SINUSES OF THE NOSE. 


diseases. So far as the author is aware, this has not only remained 
unsubstantiated but has been denied by other authorities . 6 Per¬ 
sonally I have never been able to observe it in a single case. 


PURULENT SECRETION IN THE NOSE. 

The mere presence of purulent secretion in the nose is no more 
indicative of sinus disease than its absence is a proof that no 
sinus involvement is at hand. If, however, secretion reappears in 
the same spot shortly after being removed, the evidence is posi¬ 
tive that a reservoir of purulent material is underlying, it being 
impossible for a circumscribed inflammation of the mucous mem¬ 
brane to secrete pus so rapidly in such an interval of time. 

The classical symptom of sinus empyema is the presence and 
continued reappearance of pus in a particular locality of the nose 
(beneath the anterior third of the middle turbinate for anterior 
sinus disease, in the olfactory fissure and above the posterior end 
of the middle turbinate for posterior disease). This symptom, 
when actually present, is pathognomonic; unfortunately, however, 
it is often conspicuous by its absence, particularly so at the time 
of the morning examination. The repeated absence of purulent 
secretion in the nose, especially if there exists an authentic history 
of nasal discharge, should, therefore, not be taken as proof posi¬ 
tive that sinus disease is not present, as the following case will 
illustrate: 

H. K., 38 years, fireman, referred to me on account of nasal trouble. Patient 
complained of postnasal discharge, particularly in the morning; unpleasant sub¬ 
jective odor in the nose, which sometimes affected the taste and interfered with 
the appetite. Never had headaches or, in faet, pain of any kind in the head. 

Examination: Slight hypertrophy of the anterior end of the middle turbinate 
on right. No sign of secretion even after the application of cocaine and adrenalin 
between turbinate and bulla. Left nares normal. The patient was treated ex¬ 
pectantly for some time, but continued to complain of the old trouble. Finally 
an exploratory needle puncture of the antrum was made and, much to my surprise 
and relief, a large quantity of thick, creamy pus was evacuated, showing that this 
had been the seat of the trouble. 

The particular point in this case is that at no time was the slightest objective 
symptom of sinus disease present. We had but two rather vague symptoms 
upon which to base a diagnosis: the postnasal discharge, which always occurred 
during the absence of the patient, and the cacosmia, which was, of course, purely 
subjective. Had it not been for the latter I doubt if the needle puncture would 
have been made, taking into consideration that the history of the amount of post¬ 
nasal discharge depends largely upon the imagination of the patient. Under 
these circumstances, the disease would have remained undiscovered until chronicity 
had developed. 


GENERAL CONSIDERATIONS. 


61 


The explanation of the alternate presence and absence of 
secretion in the nose depends upon the position of the head, and 
principally npon the character of the secretion. It is an estab¬ 
lished fact that when the inflammatory exudate is thick and the 
ostium large, it is possible for the sinus to drain by siphonage 
so that the entire cavity will be emptied at one drainage. These 
phenomena undoubtedly occurred in the above case, so that when 
the patient was examined the sinus was undergoing the process 
of refilling, no traces of the old secretion remaining in the nose. 

It has long been recognized by the older writers that diseased 
sinuses, particularly the maxillary and sphenoid, periodically 
empty themselves of the inflammatory exudate. Owing to the 
unfavorable situation of their ostia while the upright position is 
maintained, this usually occurs during the sleeping hours of the 
patient. The opposite is the case with the frontal sinus, for here 
the secretion accumulates during the night and may not escape 
until some time during the following afternoon. These conditions 
are undoubtedly closely linked with the exacerbations and sudden 
remissions of the headache which so frequently are associated with 
this disease. 

The absence of secretion is also observed in the so-called closed 
empyema (pyocele). (See Pathology.) The amount of exudate 
secreted is variable, depending largely upon the stage and inten¬ 
sity of the inflammation. The quantity which escapes through the 
anterior nares is no criterion of the amount actually secreted, for 
only a small portion of the original may find its exit through these 
channels. In these cases the greater portion escapes through the 
choana and is either swallowed or hawked up and expectorated. 
In acute cases and acute exacerbations of chronic inflammations 
the secretion is more profuse. 

Diminution of the secretion during the course of the disease 
is usually a sign of remission of the inflammation, but sometimes 
it is due to partial occlusion of the drainage passages with exacer¬ 
bation of the disease; however, under the latter circumstances, the 
subjective symptoms are always intensified to such a degree that 
the diagnosis is unmistakable. 

The consistency of the secretion may change from time to time, 
depending upon attacks of acute coryza, the state of the weather, 
etc. So far as the inconvenience of the patient from the secretion 
is concerned, it is seldom great unless the exudation be profuse. In 
the latter instance the constant discharge from the nose, with the 


62 


THE ACCESSORY SINUSES OF THE NOSE. 


superinduced eczema on the lip and around the angles of the nose, 
proves a source of extreme annoyance and discomfort. There is 
usually a difference in the consistency of the secretion in acute and 
chronic disease. In the acute type it is not so organized and mixes 
with the irrigating fluid to form a milky mass, while in old chronic 
cases it forms balls and lumps which sink to the bottom of the liquid. 

Cacosmia .—One symptom indirectly caused by the secretion, 
and when present is almost pathognomonic of sinus disease, is 
this subjective appreciation of an offensive odor in the nose. 
This is usually intensified by sudden sharp inspiration through 
the nostrils (sniffing). The cause of the condition is either the 
presence of some gas-producing bacteria (when the secretion is 
odorless) or from putrefaction of the secretion by saprophytic 
micro-organisms. Complete anosmia is not an uncommon symp¬ 
tom, especially if the olfactory fissure is closed by hypertrophies, 
purulent secretion, etc. The location of the secretion in the nose 
is due primarily to the position of the sinus ostium, secondarily 
to the position of the head, anatomical configuration of the nose 
as influencing the respiratory portion, pressure of hypertrophies 
and deviations of the septum. 

Adhesion, capillary attraction, and siphonage play an 
important role in influencing the permanent location of the secre¬ 
tion after it has issued from the sinus ostium.* The action of 
these forces causing the secretion to lodge in atypical positions 
may lead one into drawing false inferences. Thus pus in 
the olfactory fissure is symptomatic of sphenoid suppuration. 
When the middle turbinate lies close to the septum, capillary 
attraction may draw the secretion from the hiatus around the tur¬ 
binate into the olfactory fissure, presenting a symptom of poste¬ 
rior disease, when the pus, in reality, was secreted in one of the 
anterior sinuses. We should be, therefore, particular to always 
exclude anterior sinus inflammation in these cases before arriving 
at a final diagnosis. 

Changes in the Nasal Mucosa Depending upon Sinus Disease. 

These may conveniently be divided into acute and chronic. 

Acute. —In the first stages the mucous membrane presents the 
ordinary symptoms of acute inflammation, namely, hyperaunia and 
swelling, more or less general, depending upon the virulence of the 
attack. During this stadium the naris on the affected side is often 
oathed in thick, creamy pus. 


* Yankhauer’s article (97) gives a detailed description of the mechanism of these forces. 






GENERAL CONSIDERATIONS. 


63 


The bilateral appearance of purulent secretion has been noted by some 
observers, even though the disease was confined to one side. In these cases the 
secretion came around by way of the nasopharynx, or a perforation existed in 
the septum. 

As the acuteness subsides the inflammation tends to localize 
itself more and more in the regions of the affected sinus ostia— 
thus around the uncinate process and the anterior third of the 
middle turbinate for diseases of the sinuses, first series, and in 
the neighborhood of the spheno-ethmoidal recess and olfactory 
fissure for the second series. The mucous membrane, at this stage, 
assumes locally a more or less pale, semi-gelatinous consistency, 
often showing punctiform dots (sub-epithelial hemorrhages), 
which are particularly noticeable on the anterior end and lateral 
surface of the middle turbinate and the hiatus semilunaris. 

Chronic .—In this form of the disease the inflammatory changes 
are localized to the regions where the secretion from the diseased 
cavities comes in direct contact with the nasal mucosa. These 
changes take the form of hypertrophies and atrophies. Curiously 
enough, at that point where the inflammatory exudate first makes 
its appearance in the nose, hypertrophies (polypoid and fibrous) 
are usually present, while farther below atrophy is often the rule. 
A common example of this is seen in hypertrophy of the middle 
turbinate and atrophy of the inferior, in conjunction with sinus 
suppuration. 

THE RELATION OF POLYP FORMATION TO NASAL SUPPURATION. 

Under certain conditions purulent sinus inflammation will give 
rise to the formation of mucous polyps in the nose. As a proof 
of this assertion I quote Zarnico," who emphasizes the following 
facts: 1. Polyps are often situated around the ostiums of in¬ 
flamed sinuses. 2. They recur after extirpation. 3. The recur¬ 
rence is not prevented until the purulent process is cured. Lewis 
and Turner 23 write that nasal polyps occur more frequently in 
cases of associated sinus suppuration than in simple cases, par¬ 
ticularly in ethmoidal disease. 

Jacques 100 does not incline toward this theory, but believes 
there are numerous conditions which can give rise to the forma¬ 
tion of these structures. 


99. Zarnico (29), S. 476, 1910. 100. Jacques: Nature, Causes et Traitement des 

Polypes. Rev. hebd. d. Lary., vol. 2, p. 525, 1903. 



64 


THE ACCESSORY SINUSES OF THE NOSE. 


However, the exact status of this question remains to-day one 
of the most disputed points of rhinology. 

Since Griinwald’s 91 contention that all nasal polyps were prac¬ 
tically pathognomonic of accessory sinus disease, to Uffen- 
orde’s 101 assertion that they have absolutely no relation per se 
to it, many opinions have intervened. 

Although Griinwald has generally been given credit for the priority of 
associating polyps with sinus disease, in reality several authors had previously 
commented on this connection. Wepferi 102 probably first advanced this theory, 
based on his findings at the autopsy table. Bayer 103 also associated these two 
conditions in no uncertain terms. 

Kaufmann, 104 one of the first modern writers on this subject, 
said that in many cases empyema of the maxillary sinus was the 
only cause for the polyp formation. Several years later 
Probsting 105 stated that polyps on the processus uncinatus were 
pathognomonic for sinus suppuration. 

So far as the actual pathological findings are concerned, in 86 
per cent, of the inflammatory sinus disease Griinwald 106 found 
polypoid hypertrophy, Kronenberg 107 in 60 per cent., and Lewis 
and Turner 23 30 per cent. 

Before endeavoring to show the actual relation between these 
connections it might be wise to briefly consider the theories of 
their pathogenesis as advanced by various authors. 108 

Chiari 109 states they are due to chronic irritation of the mucosa from chronic 
catarrh or purulent inflammation of the sinuses. Griinwald 91 is of the opinion 
that they are the sequelae of purulent inflammation of the sinus mucosa. Bos- 
worth 110 advanced the theory that the starting point of the polyp was in an 
accessory sinus; an inflammatory process occurs which takes on something of a 
myxomatous character. The membrane becomes thick and of a soft, gelatinous 
consistency, and, on account of intracellular pressure, makes its appearance in the 
nose. 

Alexander 111 says the actual cause of polyp formation is the 
inflammatory swelling with disturbances in the circulation. 

101. Uffenorde (7), S. 86. 102. Wepferi: Joh. Observ. de Affection Capitis Schapusii, 
p. 903, 1727. 103. Bayer: Beitrag zum Studium u. zur Behandl., etc. Deutsch. med. 

Woch., No. 10, 1889. 104. Kaufmann: Ueber eine typische Form von Schleim, etc. 

Monat. f. Ohrenhk., p. 13, 1890. 105. Probsting: Ueber die Entwickelung von Nase, 

infolge von Nebenhohleneiterung. Verh. d. Vereins Siiddeutsch. Laryng., S. 8, 1894. 
106. Griinwald (91), S. 87. 107. Kronenberg: Schleimpol. d. Nase u. Naseneiterungen, 

S. 259, 316. Ther. Monatsh., 1897. 108. Yonge: Polypus of the Nose, p. 25,1906, London. 
109. Chiari: Krankheiten der Nase. S. 195, 1902, Wien. 110. Bosworth: Various Forms 
of Disease of the Ethmoid Cells. N. Y. Med. Journ., p. 505, vol. 2, 1891. 111. Alexander. 

Nasenp. in Beziehungen zu der Empyemen d. Nebenhohlen. Arch. f. Lary., S. 324 Bd. 
5, 1896. 



GENERAL CONSIDERATIONS. 


65 


Ilajek 112 writes that a continuing cause of polyp formation is 
purulent inflammation of a sinus. 

It will be noted that all these authors give no pathological 
reasons for their deductions, but content themselves with making 
the mere statement that polyp formation can result from sinus 
disease. The actual pathological change occurring when the pu¬ 
rulent secretion is brought into contact with the nasal mucous 
membrane has been described as follows: An inflammatory exu¬ 
date occurs beneath the mucous membrane, stasis takes place in 
the vessels with transudation into the tissues and the formation 
of a polyp. 113 Heymann 114 is of a somewhat different opinion, 
and writes that the secretion causes an irritation to the smooth 
mucosa which results in the formation of inflammatory papules. 
Hyperplasia now occurs, which affects only certain of the granu¬ 
lations, and the resulting oedema causes the formation of small 
polyps. Yonge 115 lays great stress upon the mechanical changes 
in the glands and says they undergo cystic degeneration by 
obstruction of the ducts, thereby forming the polyp. 

The consecutive changes are as follows: 

1. Chronic inflammation of the mucous membrane. 

2. Dilatation of the glands. 

3. Formation of projections on the infiltrated mucosa. 

4. Increase of the oedema. 

5. Formation of flat oedematous structures which become rela¬ 
tively constricted at the base and stretched until they constitute 
a pedicle. 

The investigations of the author do not entirely coincide with 
the above findings, particularly those of Yonge in reference to 
the occlusion of the glands. While many cases show cystic gland 
formation, there is no reason to believe that this has been the 
sole cause of the hyperplasia. 

The various stages of polyp formation from accessory sinus 
disease would seem to be: 

1. Round-cell infiltration through the mucosa, resulting from 
the irritation produced by the secretion. 

2. Arrangement of these leucocytes around the blood-vessels 
and glands, causing partial stasis and predisposing to the transn- 


112. Hajek: Warum recediviren Nasenpolypen. Wiener Med. Presse, No. 10, 1902. 
113. Zuckerkandl: Anat. der Nasenhohle. Wien, Bd. 2, S. 115, 1892. 114. Heymann: 

Handbuch der Laryngologie und Rhinologie. Die Nase, S. 788, 1900. 115. Yonge (108), 

p. 59. 

5 



66 


THE ACCESSORY SINUSES OF THE NOSE. 


dation of serum through the vessels into the surrounding tissues 
and occlusion of the glandular ostii. 

3. Dilatation of the interstitial spaces of the connective tissue 
from the pressure of the exudate with polypoid hypertrophy. 

4. Continued stasis of the blood and consequent outpouring of 
serum with gradual relaxation of the mucous membrane and true 
polyp formation. 

These pathological observations may be true as far as they 
go, but they do not explain the fact that many cases of empyema 
run their course without the slightest vestige of polyp formation. 
Alexander 111 does not believe the outflow of pus over the mucous 
membrane is the single cause, but thinks the direct continuity of 
inflammation from the mucosa of the sinuses to that of the nose 
the most important causative factor. We must, however, remem¬ 
ber that this causative factor cannot, in every case, be definitely 
determined, yet it is certain that the continued irritation from the 
inflammatory secretion at least exerts some predisposing influence 
for the formation of these structures. 

Certain authorities 116 U7 hold the opinion that nasal polyps may be the 
primary cause of a sinus empyema by occlusion of their ostii. This genetic 
relation, however, has not been sufficiently proven. 

If one makes a brief retrospection of this subject it will be 
seen that polypi occur in a certain percentage of accessory sinus 
suppurations. It apparently does not depend upon which sinus is 
affected, although they occur more often with ethmoidal disease. 
(See Pathology of Ethmoid Labyrinth.) They often occur en¬ 
tirely disassociated with sinus suppuration, and vice versa . Why 
they occur in certain cases of sinus suppuration and not in others 
is as yet unexplained. 

Solitary Choanal Polyps. 

These rather infrequent hyperplasias are usually single and 
grow to such a size that they practically occlude the greater part of 
the nasopharynx, often appearing well below the uvula (Plate 2a). 
Their resiliency and free mobility, as well as their color and density, 
allow them to be immediately differentiated from true naso-fibroma. 
The choanal polyp is of peculiar interest to us in that its origin is 
usually in the mucosa of one of two sinuses: the maxillary 117a or 

116. Lichtwitz: Bresgen’sche Sammlung Zwangloser Abhandiungen aus dem Gebiet 
den Nasen, Ohren, Mundund Halskrankheiten. Halle, 1896. 117. Fischenitz: Discussion. 
Verh. Siiddeutsch. Lary., S. 14, 1894. 117a. Killian: Ursprung der Choanalpolypen. 

Verh. Siiddeutsch. Lary., S. 132, 1905. 



PLATE 2 A. 








Large polyp extending into pharynx. 


Uvula retracted. 





















r 





















































/ 



























GENERAL CONSIDERATIONS 


67 


the sphenoid. 117b It is not necessary that these sinuses be puru- 
lently inflamed, as these polyps appear to have the same relation 
to them as ordinary ones do to the ethmoid in hyperplastic ethmoid- 
itis. Citelli 1176 believes their genesis due to an infection following 
which a portion of the mucosa becomes loose from the underlying 
bone between which a collection of serum forms. The mucosa 
becomes loosened in greater area until it begins to protrude into 
the nose through the natural ostium. In this manner the polyp is 
gradually formed. The following illustrates a case possibly of 
this origin: 

A. B., seen in consulation with Dr. Ridpath. Anterior rhinoscopic examination 
presented a nasal cavity choked with polyps. On examination of the throat a large 
polyp was seen behind and hanging below the uvula (Plate 2a). This was freely 
movable in all directions, and only caused annoyance by its mechanical interference 
with the action of the soft palate. The operation consisted of removing the polyps 
in the anterior nasal chamber, when suddenly the patient gagged and expectorated 
the entire polyp with long pedicle into his hand (Plate 2a). It was afterwards 
noted that the remains of the pedicle were in the middle nasal passage near the pars 
membranacea and could be traced into the maxillary sinus. 1170 

Choanal polyps have also been reported in children, although 
the condition appears to be a very rare one. One of these originat¬ 
ing in the sphenoid sinus of a child, aged six, has been reported 117d 
in which no symptoms of infection or suppuration were present. 

Other Changes in the Mucosa Depending upon Sinus Disease. 

Eczema of the nasal vestibule, particularly were confined to 
one side, is an indication of an increased unilateral discharge, and 
should immediately call attention to the sinuses of that side. 
Eczema of this character often persists for years until the con¬ 
comitant sinus empyema is discovered and cured, the presence of 
which had hitherto not even been suspected. 

ERYSIPELAS. 

The precise relation of this disease to sinus affections seems to 
be a mooted question. Some authorities consider erysipelas as the 
primary lesion; others believe that it is secondary, being due to sub¬ 
sequent infection following the irritation from the secretion. Both 
theories appear, under certain circumstances, to be correct, as 
proven by the observations of Weichselbaum (erysipelas primary) 
and Hajek (empyema primary), but it is probable that empyema 
is responsible for the erysipelatous outbreak. (See ^Etiology.) 

117b. Kubo: Ueber die Sphenochoanalpolypen. Arch. f. Lary., Bd. 27, S. 213,1913. 
117c. Baum: Two cases of Naso-Pharyngeal Polypus originating in the Maxillary Sinus. 
Laryngoscope, p. 180, March, 1918. 117d. Moore: Choanal Polypus Originating in the 

Sphenoidal Sinus of a Child Aged Six. Proc. Royal Soc. Med. Sec. Laryng., March, 1917. 
117e. Citelli: Ueber eine neue Krankheit der oberkieferhohle. Arch v. f. Laryng., S. 37; 1920. 



68 


THE ACCESSORY SINUSES OF THE NOSE 


Partial and complete anosmia are due to two causes: (1) me¬ 
chanical (from occlusion of the olfactory fissure by hyperthrophies, 
secretion, etc.), or (2) peripheral (from pathologic degeneration 
of the olfactory cells in the mucous membrane due to the constant 
irritation from the secretion). The later condition results from 
posterior ethmoid or sphenoid disease. 

Changes in the Mucosa of the Upper Respiratory Tract. 

THE NASOPHARYNX AND PHARYNX. 

In acute forms of sinus affection these structures usually remain 
unchanged. Only in those cases of extreme virulence is a hyper- 
semia and swelling of the pharyngeal mucosa present. The chronic 
forms of sinus empyema are frequently associated wdth pharyngeal 
disturbances. These are of two varieties: 1. Pharyngitis sicca. 

2. Pharyngitis lateralis (granular or hyperplastic). 

Pharyngitis Sicca .—This form of the disease does not differ 
essentially from the ordinary variety of sclerosed pharynx. One 
symptom, however, when present, is very suggestive of sinus in¬ 
volvement, particularly posterior; that is, accumulation of thick, 
tenacious secretion on the postpharyngeal wall, which is particu¬ 
larly difficult to dislodge, even with a cotton mop. 

The form of dry pharynx which accompanies sinus disease is 
differentiated by the fact that it seems to assume its greatest 
intensity high up in the nasopharynx and gradually disappears in 
the depths below the pharyngeal pillars; however, no sharp line of 
demarcation is to be noted. True atrophy of the mucous mem¬ 
brane occurs in this form of the affection. The epithelial changes 
are due to the drying of the secretion on the mucosa. 

Pharyngitis lateralis is characterized by a definite area of in¬ 
flammation on the lateral wall of the pharynx behind the posterior 
pillar of the tonsil. The breadth of the inflammatory tract may 
vary from the mere streak to the size of an ordinary lead-pencil. 
This form is frequently seen in posterior ethmoidal and sphenoid 
suppuration, although the backward flow of pus from any of the 
sinuses can give rise to the condition. It is caused by the constant 
flow of purulent secretion over the certain tract at the juncture of 
the posterior and lateral pharyngeal walls. Uffenorde 118 lays par¬ 
ticular stress upon the importance of this form of pharyngitis in 
relation to accessory sinus empyema. 

118. Uffenorde: Pharyngitis Lateralis. Arch. f. Lary., Bd. 19, S. 10, 1906. 




GENERAL CONSIDERATIONS. 


69 


LARYNGEAL AFFECTIONS. 

These are not an infrequent accompaniment of sinus suppura¬ 
tion and are probably caused by the constant bathing of the parts 
with the secretion which has flowed backward into the pharynx. 
The inflammatory changes in the mucosa are always found on the 
posterior laryngeal wall and evidence themselves by hypersemic 
swellings of the aryepiglottic folds and arytenoid cartilages. In 
severe cases the posterior third of the vocal cords is affected, with 
more or less oedema of the ventricular bands. This cedemic infiltra¬ 
tion is often so great as to seriously interfere with the mobility of 
the structures of vocalization. 

Various degrees of hoarseness seem to be the predominant 
laryngeal symptoms. This disturbance of vocalization is due to 
two causes. 1. The swelling and oedema of the arytenoidal region, 
causing mechanical interference with the motions of the vocal 
cords. 2. Tiring of the extrinsic muscles by the constant hawking 
and attempts to clear the throat of the inspissated secretion. Some 
form of pain, or, at least, of irritation, is also usually located in 
the larynx. 

It occasionally happens that the sore throat and laryngeal 
symptoms (hoarseness, etc.) are the only subjective symptoms 
present, and on this account alone has the patient sought medical 
advice, never having the slightest intuition that the exciting cause 
of his discomfort lay in one of the accessory sinuses. The follow¬ 
ing case will illustrate the point: 

This hoarseness may even simulate acute pulmonary tuberculosis (which was ap¬ 
parently substantiated by the X-ray) * and be treated as such until purulent 
secretion was discovered issuing from the posterior ethmoid and sphenoid sinuses. 
Appropriate measures were instituted to establish proper drainage and aeration 
with the prompt disappearance of the hoarseness and all pulmonary symptoms. 118 ® 

F. D., physician, consulted me for a sore throat which had been annoying him 
for several months. He also complained of recurrent attacks of hoarseness which 
always occurred toward evening, and particularly after exceptional vocal usage or 
sudden changes in the weather. No other history was obtainable except that of a 
moderate coryza. 

Examination of the larynx showed a mild type of subacute laryngitis, arytenoids 
somewhat swollen and engorged, vocal cords moderately hypersemic, otherwise nor¬ 
mal. Nose apparently normal in spite of the history of coryza. The usual treat¬ 
ment for laryngitis was instituted and continued for some time, with no appreciable 
change in the condition. One morning he chanced to speak of the cold in his head 
which he could not rid himself of, and I suggested that perhaps he had some sinus 
trouble, although none of the usual symptoms were present. An exploratory needle 
puncture of the maxillary sinus was proposed, to which he readily acquiesced. The 
right antrum was first punctured and lavaged with negative results; however, as soon 
as the needle was introduced into the left sinus and air injected, a bubbling sound 
told the presence of secretion. 


70 THE ACCESSORY SINUSES OF THE NOSE. 


On washing out the sinus a large quantity of heavy, ropy pus was expelled from 
the cavity. This treatment was continued until the cavity discontinued to secrete, 
which required only a few lavages. The pharjmgeal and laryngeal symptoms showed 
immediate improvement and gradually disappeared without further treatment. 

Griinwald 119 lays particular stress on this point and says: 

4 4 An examination of a patient with chronic laryngeal affection 
must be considered incomplete until the exact condition of the nose 
and nasopharynx has been thoroughly investigated.” 

PHAKYNGEAL AFFECTIONS. 

The symptoms resulting from pharyngeal disturbances depend¬ 
ing upon sinus disease are either those of attacks of angina, often 
occurring as a result of infection of the tonsillar lacuna from the 
secretion, or those caused by the chronic pharyngitis. In the latter 
instance the symptoms are occasioned by the continual irritation 
of the drying secretion, causing constant hawking and rasping 
and resulting in the exquisitely irritable pharynx which is so often 
encountered in patients suffering with accessory sinus disease. 

Bronchial symptoms, asthma, bronchitis Lichtwitz, 120 
Hartmann, 121 Hajek 6 ), bronchiectasis (Lichtwitz, 120 Krauss, 122 
Mullin 122a ), and emphysema (Uffenorde 7 ) have been from time to 
time reported as complicating accessory sinus empyema. 

Gastric disturbances 123 ’ 124 are not infrequent accompaniments 
of sinus suppuration. These range from slight eructations of gas 
to active nausea and vomiting, and undoubtedly result from the 
constant swallowing of the purulent secretion, with reabsorption of 
ptomaines. 125 Vomiting may also occur from the irritation pro¬ 
duced by continued efforts to dislodge the dried secretions in 
the nasopharynx. 126 

Remote Local Symptoms. 

Dizziness and Vertigo .—These manifestations are a frequent ac¬ 
companiment of sinus suppuration. Dizziness is often more marked 
on stooping over to pick up something from the ground or on sudden 
motions of the head. In severe cases it may occur whenever the pa- 

118a. Myers: Hoarseness caused by thyro-arytenoid interni parersis with symptoms 
simulating acute pulmonary tuberculosis due to a sinus infection. Laryngoscope. Dec. p. 
720, 1919. 119. Grunwald (91), S. 97. 120. Lichtwitz: Die Eiterungen der Nebenhohlen 

der Nase und ihre Folgezustande in anderen Korpertheilen. Bresgens Sammlung, Bd. 1, 
No. 7,1895. 121. Hartmann: Zur Casuistik der Highmorshohlenempyeme. Deutsch. med. 

Woch, No. 50, S. 1026,1889. 122. Krauss: Arch. f. Larv., Bd. 13, S. 45,1902. 122a. Mul- 

lin: The Accessory Sinuses as an Etiologic Factor in Bronchiectasis. Ann. of Otol. Rhin. 
and Lary., Sept., 1921. 123. Storck: Gastric Disturbance Due to Diseases of the Frontal 

Sinus. New Orleans Med. and Surg. Journ., vol. 59, p. 547. 1907. 124. Zabel: Eiteriiber- 

schwemmung des Magendarmcanals aus Nasennebenhohlenempyem, etc. Deutsch. med. 
Wochenschr., Bd. 36, .S. 797, 1910. 125. Scherer: Salzsaueremangel bei Nebenhohleneiter- 

ungen. Verh. deutsch. Laryngologen, S. 147.1907, Dresden. 126. Uffenorde: Behandlung 
u. diagnostichen Symptomen. Zeitschr. f. Artzliche Fortbildung, No. 12, 1909. 



GENERAL CONSIDERATIONS. 


71 


tient makes any attempt at locomotion. 127 Vertigo may suddenly 
manifest itself while the patient is at rest, sitting and reading. It is 
usually but of momentary duration, although it may be so severe as 
to excite nausea and even vomiting. Reclining at full length will 
usually terminate these attacks. 

PSYCHICAL AND INTELLECTUAL DISTURBANCES . 128 

These occur more particularly in the chronic form of the dis¬ 
ease and manifest themselves as all kinds and conditions of symp¬ 
toms referable to disturbed mental equilibrium. They begin in 
a mild and insidious manner, the patient usually having occasional 
lapses of memory and slight mental wanderings while the mind is 
concentrated on business affairs. As time elapses and the disease 
wears on, these symptoms become more and more pronounced, until 
a decided effort to concentrate the mind is required, which naturally 
results in disinclination to any form of work requiring mental ef¬ 
fort. Unless the disease is checked at this point, the condition will 
steadily progress until a state of neurasthenia prevails, the patient 
exhibiting alternate periods of excitability and moroseness, a pecul¬ 
iar antipathy toward friends, especially immediate relations, vari¬ 
able temper, marked indolence and carelessness in dress and general 
appearance, great mental depression, melancholia, and even suicidal 
tendencies. 129 The relative severity of these symptoms appears to 
depend upon the condition of drainage, as they are always relieved 
by permanent ventilation of the sinuses. They are also accentuated 
by the exacerbations of the headache, and many authors consider 
that these are directly responsible for their appearance. 

Griinwald 130 believes that the chronic sinus suppuration influ¬ 
ences the brain by disturbing the lymph circulation at the base of 
the cranium. Robertson 131 considers the reflex vasomotor stasis of 
blood in the meninges to be the exciting cause. One would be in¬ 
clined to place the blame on the reabsorption of toxins through the 
sinus walls into the cerebral circulation; however, as Hajek 132 well 
puts it, “One cannot definitely explain the exact nature of the dis¬ 
turbances of the brain function in these conditions.’’ It is, how¬ 
ever, certain that no tangible anatomical changes occur, as the psy- 

127. Skillern: Ein Fall von Geschlossenen Empyemen u. s. w. Zeitsch. f. Lary., S. 337, 
Bd. 1, 1909. 128. Ziem: Ueber Beziehung d. Nasenkrankheiten z. Psychiatrie. Mon. f. 

Ohren., S. 482, 1897. 129. Stucky: Some Mental Symptoms Due to Disease of the Nasal 

Accessory Sinuses. Lancet-Clinic, Jan. 19,1907. 130. Griinwald: Lehrbuch, S. 115,1896. 

131. Robertson: Headache from Non-SuppurativeInflammation of the Accessory Sinuses. 
Journ. Am. Med. Assn., March 5, 1904. 132. Hajek (6), S. 24. 



72 


THE ACCESSORY SINUSES OF THE NOSE. 


chical alterations, for the most part quickly vanish after thorough 
drainage is established. 

Personally the author is of the opinion that certain of these mental disturbances 
(phychologic) bear no more relation to the sinus affections than a corresponding 
disease in any other part of the human economy. That they occur with greater fre¬ 
quency in the sinus inflammations cannot be gainsaid, but how often does the 
gynaecologist, for example, encounter precisely the same condition among females 
afflicted with ovarian and uterine affections! It is the corporeal condition, not the 
specific disease, that provokes these manifestations. 

General Symptoms. 

RHEUMATISM AND RHEUMATIC PAINS. 

It has now been definitely established that local infections, even 
though so slight as not to attract attention to themselves (roots of 
teeth, tonsils, etc.), can be the direct and sole cause of rheumatoid 
affections of muscles and joints in remote portions of the body. 132c 
This has also been established in connection with the sinuses, par¬ 
ticularly so in obscure ethmoid 132a and sphenoid disease. It is 
probably due to toxins eliminated by the infecting micro-organism 
as improvement is usually noted immediately after the focus of 
infection is removed. 132b 

FEVER. 

Fever is always present with acute inflammation and acute 
exacerbations of chronic affections, but exhibits no especial note¬ 
worthy characteristics. The sudden rise of temperature in chronic 
inflammation is indicative of toxic reabsorption through the sinus 
walls or of a pending and severe complication, such as rupture, into 
the neighboring parts. 

CIRCULATORY DISTURBANCES. 

These range from slight acceleration of the pulse, disassociated 
with any increase in temperature, to an actual condition of general 
congestion. The former condition, though there may be no increase 
in the blood-pressure, seems to affect the veins of the head as well 
as the arteries, and I have often noted the unwonted prominence of 
the superficial temporal veins in patients during this period of con¬ 
gestion. The symptoms of this condition consist in flushing of the 
face, acceleration of the pulse’ occlusion of the affected, and often 
both, nares, prominence of the superficial veins of the temple and 
forehead, visual disturbances and general irritability of the indi¬ 
vidual. They may occur at any time, but are usually synchronous 
with the occlusion of drainage. 

132a. Thompson: An unusual Infection From Ethmoiditis. Laryngoscope, p. 643> 

1917. 132b. Rochester: Sinusitis as a Source of Systemic Infection. Journ. Opht.hal. and 

Oto-Laryng., Aug. 1917. 132c. Williams: Latent Sinusitis in relation to systemic infections 

especially with reference to rheumatoid arthritis. Journ. Laryng., July, 1919. 



GENERAL CONSIDERATIONS. 


73 


A marked predisposition to sleeplessness is often coincident with 
the period of congestion. Actual insomnia, while often present, 
does not seem to play as important a role as the restless, dreamy 
sleep, which seems to possess no refreshing qualities, consequently 
the sufferer finds himself in no condition to attend to his ordinary 
business affairs on arising in the morning. 

NERVOUS DISTURBANCES. 

General nervousness in connection with sinus disease is only to 
be expected with the symptoms described above, and should be 
viewed merely as one of the constituents of the general symptom- 
complex. One of the commonest of these is a feeling of great 
weakness which suddenly appears and totally incapacitates the indi¬ 
vidual while present. Periods of depression sometimes so severe as 
to border on melancholia are not uncommonly associated with 
chronic sinus disease. The patient is seized with sudden attacks 
of great depression, during which he is sullen, morose, and ex¬ 
tremely apprehensive, often exhibiting particular antipathy 
towards members of the immediate family circle. This, is, perhaps, 
more marked in chronic frontal sinusitis than all of the other cavi¬ 
ties combined, with the possible exception of the sphenoid; indo¬ 
lence and intolerance toward mental work of any description are 
practically always associated with these periods of depression, so 
that the patient is unable to follow his usual occupation. 

Albuminuria and even acute nephritis 133 have been found to be 
directly associated with and probably dependent upon purulent 
sinus disease. In the event of these two occurring simultaneously 
the cause of the headaches might be obscured when albumen is found 
in the urine. Under these circumstances, it is wise to treat the sinus 
condition and the kidney affection as separate entities in order to 
give the patient the benefit of the doubt and clear up the conditions 
at the earliest possible moment. This is but another argument in 
favor of early urinalysis in all cases of suspected sinusitis. 

SEXUAL APPARATUS. 

Inflammation of the sinuses often exercises a marked influence 
over the sexual function. In ordinary cases there is a marked 
deterioration, while in the severe cases it may be totally abolished. 

Diagnosis—First Series. 

When a patient presents himself for examination, and a sinus 
disease is suspected, our first thought will be to examine for free 

133. Keiper: Frontal Sinusitis a Probable Cause of Acute Nephritis. Laryngoscope, 
p. 449, 1917. 




74 


THE ACCESSORY SINUSES OF THE NOSE. 


pus in the nose. We will suppose, then, in the middle nasal 
passage pus is seen coming down between the bulla and middle tur¬ 
binate. Now the all-important point is to ascertain whether this 
secretion is the overflowing of a reservoir or merely due to circum¬ 
scribed inflammation of the mucous membrane. This is readily dis¬ 
tinguished by merely wiping it away with a cotton mop. If it 
reappears within a few moments a larger quantity is somewhere 
concealed, as it is manifestly impossible for the nasal mucosa to 
secrete such a quantity in so short a time. This is, therefore, one of 
the principal steps in the diagnosis, namely: not the mere presence 
of pus in the nose, but its continued reappearance after wiping 
away is a positive symptom of sinus disease. 

We must bear in mind that purulent secretion in the nose can be caused by 
several conditions, such as foreign bodies, mucous surfaces in apposition (polyps, 
hypertrophies, etc.), adenoids, atrophic rhinitis, tuberculosis, syphilis, and malig¬ 
nant tumors. Of these the only condition that is liable to be confounded with sinus 
disease is polyp and hypertrophic formation associated with secretion. As these are 
often dependent upon one another, they require particular mention. (See Rela¬ 
tion of Polyps to Empyema.) 

We have thus far demonstrated to our own satisfaction that 
purulent secretion is present in the middle nasal passage which 
reappears shortly after removal. Our next step is now to ascer¬ 
tain which particular sinus or sinuses of the first series are secret¬ 
ing the pus. For this purpose we first turn our attention to the 
maxillary sinus, and for the following reasons: a. It is more fre¬ 
quently affected than the others, b. It is situated at the lowest 
portion, c. It is reasonably easy of access. A canuula is bent, corre¬ 
sponding to the side affected, and an attempt is made to find an 
accessory ostium, which occurs in about ten per cent, of all cases. 
This will probably fail. The normal ostium should then be sought 
for, but this also usually miscarries. There remains but one method 
of ascertaining whether pus is present in the maxillary sinus, and 
that is by needle puncture. (See Maxillary Sinus.) This being 
accomplished, we will suppose that a quantity of purulent secretion 
appeared in the basin. We are now sure of one point, i.e., pus was 
present in this sinus. Our next thought is to learn whether the in¬ 
flammatory product has been secreted by the maxillary mucosa, or 
whether the antrum had merely acted in the capacity of a receptacle 
for pus which had been secreted in one of the overlying sinuses. As 
it is impossible to determine this offhand, the patient is requested 
either to wait or return in an hour or two for further examination. 
If at the end of that time distinct traces of pus are noted beneath the 
middle turbinate, we can definitely say that one of the sinuses higher 
up (frontal or anterior ethmoid) is affected. 


GENERAL CONSIDERATIONS. 


75 


We have thus far learned that the maxillary sinus contained pus 
and that either the frontal or ethmoidal, or both, may be secreting. 
To further facilitate our diagnosis, it is wise to refract the middle 
turbinate toward the septum by means of the long Killian speculum, 
or, better still, a long, dull instrument such as used for a submucous 
resection of the nasal septum. (See Frontal Sinus.) In this way 
we procure much more room and are better able to judge the condi¬ 
tions existing between the uncinate process and the bulla. An at¬ 
tempt should now be made to introduce a sound into the frontal 
sinus, and, if this succeeds, to bend a cannula after the curve of the 
sound and blow air into the cavity, keeping the eye on the highest 
visible portion of the cannula for the appearance of pus. 

If the introduction of the catheter fails, it will be necessary to 
infract or resect the anterior end of the middle turbinate. (See 
Frontal Sinus.) The presence of polyps or hypertrophies may pre¬ 
vent further access to the frontal sinus, under which circumstances 
it will be necessary to remove these before a probe can be introduced 
into the sinus cavity. The frontal sinus is now washed out, and 
if pus in an appreciable quantity is expelled we can state with 
certainty that this cavity is diseased and has secreted the puru¬ 
lent material, for it cannot act as a reservoir for another sinus 
on account of its high situation. Our findings are now as fol¬ 
lows : Frontal sinus diseased; maxillary sinus contained pus, and 
ethmoid unexplored. 

It is now an easy matter to differentiate whether the maxillary 
sinus is actually diseased or not, for after the drainage passages 
of the frontal have been cleared by resection of the middle turbinate 
the secretion finds its way into the nose instead of being directed 
backward into the ostium of the maxillary sinus, consequently after 
a few days of treatment to the frontal sinus, on making a needle 
puncture of the maxillary, it will be found empty. If, however, 
secretion is continually found in the latter, we can definitely de¬ 
termine the condition confronting us by the following experiment: 
After thorough lavage of the maxillary as well as the frontal, a 
pledget of cotton is inserted into the superior portion of the hiatus 
in such a manner as to exclude all secretion coming down from 
above. After a period extending from several hours to one day, 
depending upon the profuseness of the secretion, the nose is again 
examined. If no pus is to be found beneath the pledget of cotton, 
it is probable that the maxillary is healthy. Needle puncture will 
positively determine the correctness of this supposition. If, how¬ 
ever, pus is seen below, the maxillary is either diseased or the secre- 


76 


THE ACCESSORY SINUSES OF THE NOSE. 


tion has leaked through the cotton. On removal of the plug the 
secretion from the frontal immediately descends into the nose. 

Differentiation between frontal sinus empyema and suppura¬ 
tion of the anterior ethmoidal cells is more or less of a rhinological 
nicety. When, however, the bulla alone is affected, the secretion 
appears farther back in the hiatus, because the ostium is situated 
in the angle where the middle turbinate joins the bulla and not at 
the lowest portion of the latter. As a matter of fact, it is now 
generally conceded that when frontal sinus disease exists the ante¬ 
rior ethmoid cells (infundibular cells) are similarly affected. As 
the therapy in both instances is practically the same, further dif¬ 
ferentiation of these subjects would seem superfluous. 

Diagnosis—Second Series. 

Recalling the positions of the sphenoidal and posterior 
ethmoidal ostia, we shall at once see that any secretion from these 
sinuses must appear in either one of two places: a. The olfactory 
fissure, b. In the choana above the posterior end of the middle tur¬ 
binate. Supposing, then, pus was seen in the olfactory fissure be¬ 
tween the middle turbinate and septum, which returned immediately 
after removal, what would be our first step in ascertaining its 
source? We know that normally the anterior wall of the sphenoid 
is hidden from our view by the middle turbinate, and is only visible 
under certain conditions. (See Anatomy of Sphenoid.) As it is 
essential that we first learn whether the sphenoid is secreting, an 
unobstructed view of the ostium is required. For this purpose one 
makes use of the long Killian speculum, endeavoring to push aside 
the middle turbinate, thus widening the olfactory fissure. In the 
majority of instances this will not give us a satisfactory view of the 
spheno-ethmoidal region. 

We must now attempt to introduce a sound into the ostium, not 
only for the purpose of ascertaining its position but to facilitate the 
subsequent introduction of a cannula. Suppose our attempt has 
been successful and we have washed out the cavity and brought 
away a considerable quantity of pus: are we in a position to make 
an accurate diagnosis? Absolutely, no. We have merely demon¬ 
strated that the sphenoid sinus contained pus, but we can not state 
with certainty whether the purulent material was secreted by the 
mucosa of the sinus or whether it is afterwards infiltrated into the 
cavity. We are not even certain that the sphenoid contained pus, 
for, the ostium being invisible, none was seen issuing therefrom, and 
it is possible that the accumulation was washed from the region of 
the spheno-ethmoidal fissure. 


PLATE 2 B. 



. View through the nasopharyngoscope of the sphenoidal region. Sound penetrating 
ostium of sphenoid sinus. Granulation around ostium, pus exuding below point 
of sound. 



GENERAL CONSIDERATIONS. 


77 


A most useful instrument to use at this point is the naso- 
pharyngoscope. By its aid we can not only guide the point of the 
sound into the ostium of the sphenoid sinus, but in many instances 
actually see the purulent secretion as it exudes from the sinus. The 
region of the posterior ethmoidal cells can be equally well exam¬ 
ined by turning the instrument and obtaining the proper focus. 
(Plate 2b.) 

Following the lines already established, i.e., when in doubt to 
follow the secretion to its source, nothing remains but to remove 
all structures interfering with this procedure, viz., posterior half of 
the middle turbinate. This being accomplished, the nasal portion 
of the sphenoidal wall, with the ostium, is usually visible. We are 
now in a position to make the following observations. Bearing in 
mind that it is possible to have the following conditions in this 
locality: (1) sphenoidal empyema, (2) posterior ethmoid empyema, 
(3) combined empyema, (4) pyosinus in the sphenoid—how will we 
proceed to differentiate ? 

We will assume that pus is seen exuding from the ostium of the 
sphenoid; a cannula is introduced and the cavity thoroughly 
cleansed. The patient is allowed to remain near by, either reclin¬ 
ing on his back or in a sitting posture with the head bent backward, 
for twenty to thirty minutes. 

In this position the ostium of the sphenoid is at the top of the sinus, so that no 
escape of the secretion can take place. 

After this time an examination is made, and if no purulent 
secretion is found on the anterior sphenoidal wall we can be reason¬ 
ably sure that the posterior ethmoid cells are not affected. Some¬ 
times, however, this experiment fails, the time being too short to 
allow the secretion to form. If this proves to be the case, we make 
use of the following procedure: The sphenoid cavity being cleansed, 
the ostium is firmly plugged with a pledget of cotton, not hesitating 
to widen it with a curette if found to be necessary. If, on examina¬ 
tion the following day, no secretion is seen outside of the cotton, 
and, on removing the plug, pus spurts out of the ostium, a positive 
diagnosis of uncomplicated sphenoidal empyema is apparent. If 
the purulent material is seen on the outside and, on removal and 
lavage, no more is obtained from the sphenoid sinus, we can be sure 
that the posterior ethmoid cells are affected and the pus found 
earlier in the sphenoid had oozed in from these cells. Suppose, 
however, pus was present on both sides of the cotton plug: then we 


78 


THE ACCESSORY SINUSES OF THE NOSE. 

are either dealing with a case of combined empyema, or our plug of 
cotton has leaked. It is always wise, under these circumstances, to 
make consecutive pluggings until it is settled beyond all doubt that 
secretion comes from both cavities. 

Pyosinus in the ethmoid as a result of suppuration in the 
sphenoid is not possible, except to a very limited degree, on account 
of the anatomical configuration of the parts. A spheno-etlimoidal 
cell situated above the sphenoidal wall may become infected and 
render more difficult the diagnosis. In such a case the purulent ma¬ 
terial would appear continually on the sphenoidal wall, yet the sinus 
itself would be free. This is merely another instance of following 
the secretion to its source in order to clear up the diagnosis. Hajek 
(S. 336) reports such a case. In conclusion, it is only necessary to 
emphasize that the secretion must be followed to its source before a 
correct diagnosis can be reached. This is often a matter of days 
and even weeks, and speaks very forcibly against the probability 
of making reliable diagnosis by a single, superficial examination. 

Diagnosis by Means of (1) Transillumination, (2) Rontgen 
Ray, (3) Suction, and (4) Tuning-Fork. 

TRANSILLUMINATION. 134 ’ 135,136 ’ 137 ’ 139,140 

The rationale of this method is to place a small electric lamp in 
such a position that the rays of light will penetrate the sinus, thus 
permitting one to obtain an idea of the internal conditions. For 
this purpose an absolutely dark room is required; where this is not 
feasible, a dark cloth covering the head of the patient and operator, 
such as used by photographers, may be substituted. 

Maxillary Sinus .—A small electric lamp is placed in the pa¬ 
tient’s mouth and the current applied until the face is luminous. 
(Plate 3.) This will also illuminate the maxillary sinuses. If one 
sinus remains decidedly dark and the other light, we assume that 
some affection is present in the dark sinus which excludes, to a 

134 . Heryng: DieElektr. Durchleuchtung der Highmorshohleshohle beim Empyema. 
Berlin klinische Wochenschr., Nos. 35, 36, 1889. 135 . Ziem: Durchleuchtung oder Pro- 

bespulung die Kiefer und Stirnhohle Berlin klinische Wochenschr., No. 24, 1891. 136 . 

Vohsen: Zur Elektr. Beleuchtung und Durchleuchtung etc Berlin klinische Wochen¬ 
schr., No. 12, S. 374, 1890. 137 . Davidsohn. Die Elektr Durchleuchtung der Gesichts 

Knochen. Berlin klinische Wochenschr., Nos 27, 28 1892. 138 . Kelly: Suppuration in 
the Antrum of Highmore Glasgow Med. Journ., Feb.; 1892. 139 . Cobb: Transillumi¬ 

nation of the Nasal Accessory Sinuses during Acute Coryza. Sec. on Laryn., Trans. A. 
M. Assn., p. 172, 1902. 140 . Caldwell: Transillumination of the Accessory Sinuses of 

the Nose. New York Med. Journ., Nov. 4, p. 528, 1893. 



PLATE 3. 



Transillumination of maxillary sinus. Right side normal. Left side diseased. 




































































































GENERAL CONSIDERATIONS. 


79 


greater or lesser degree, the light. The dark shadow is, of course, 
in direct ratio to the density of the affection. In addition to direct 
transillumination of the anterior sinus wall, light in the pupil, 137 
translucency of the infra-orbital region, 134 and susceptibility of 
the patient toward the light of the lamp on the sound side, 138 have 
been advanced as particularly diagnostic for empyema of the maxil¬ 
lary sinus. Unfortunately, however, one can place but little re¬ 
liance on these findings, for the following reasons: (1) The bony 
structures through which the rays of light must pass (palatal proc¬ 
ess of superior maxillary, lateral nasal wall, and walls of antrum) 
may be unlike in thickness and density. (2) The maxillary sinuses 
may be of unequal size. (3) The light may not he held directly in 
the centre of the roof of the mouth. 

The importance of this is at once 
manifest if one moves the lamp 
around the mouth and compares the 
changes in the intensity of the light 
on both sides. These disadvantages 
can be considerably overcome by 
using the following technic: 

Coolidge’s Method .—Instead of 
placing the lamp in the centre of the 
mouth, it is inserted in the gingivo- 
buccal fold above the last molar 
teeth, as far posterior as possible. 

The light rays thus penetrate the 
external antral wall, which is con- Fio. 32.—Method of holding the lamp 

. , ........ -ii -i against the inferior wall of the frontal sinus 

siderably thinner and broader than fortransiiiuminating. 
the inferior (Figs. 36 and 39). The lamp is applied first to one 
side, then to the other, and the difference in illumination noted. 
This method will often give positive findings after the usual one 
has failed, and should always be included in the ordinary methods 
of transillumination. 

In doubtful cases I have often been greatly assisted in examining 
the inner nares in the dark room under the transillumination. It 
is surprising the difference in the illumination between the lateral 
nasal wall of the diseased and healthy side. Even though some 
doubt is present during ordinary transillumination, a comparison 
or the lateral nasal walls, through the nasal speculum under trans¬ 
illumination, will often clarify the diagnosis. On the diseased side 
that portion beneath the inferior turbinate appears quite dark when 
compared to the opposite side and in some cases the shadow will be 



80 


THE ACCESSORY SINUSES OF THE NOSE. 


quite as marked in the middle nasal passage. It would seem, at least 
in my hands, that this test when positive is one of the most reliable 
ones at our disposal to determine the presence of purulent material 
or thickened mucosa within the maxillary sinus. 

Frontal Sinus .—A metal cover is placed over the lamp so that 
the rays will escape only at the tip. The end of this is applied 
firmly against the floor of the frontal sinus at the inner angle of the 
eye, care being taken to exclude all light from escaping. (Fig. 32.) 
The best instrument to use is the double lamp, so that comparison 
can be made without changing. The current is now applied and the 
two sides compared. If one appears considerably lighter than the 
other, it is presumed that the side remaining dark is diseased. 

Ethmoid Cells .—It has been contended that the anterior ethmoidal cells are 
subject to transillumination so that reliable conclusions may be deducted. 141143 I 
have never been able to satisfactorily obtain this result although attempted on 
every possible occasion. It would seem that this has been now more or less 
generally abandoned. 

The early writers considered transillumination a most import¬ 
ant and reliable adjunct to our means of diagnosis, which, how¬ 
ever, later results have failed to justify. It has now been shown 
that iregularity in the thickness of the bony walls will lead to all 
sorts of errors in diagnosis. 143 Purulent secretion is frequently of 
unlike consistency, some being perfectly opaque, some throwing a 
well-defined shadow. The value of transillumination from the 
author’s personal stand-point may be briefly stated as follows. It 
should only be used as an adjunct to the diagnosis; thus, if maxil¬ 
lary sinusitis is suspected, we will say, on the left side, and on trans- 
illumination a distinct shadow is cast over this portion of the face, 
we can assume that the disease is probably present. I would not 
perform a radical operation on this assumption alone before sub¬ 
stantiating the diagnosis by needle puncture. 

With the frontal sinus the circumstances are somewhat dif¬ 
ferent. It is impossible to make a needle puncture in this cavity, 
so that more reliance must, of a necessity, be placed on the trans¬ 
illumination. Even here an external operation is not justified on 
the results of this test alone, and not until the presence of disease 
has been corroborated by all other means of diagnosis at our com¬ 
mand should we attempt any radical operative procedure. 

141 . Robertson: Electric Light in Antral Disease. Joum. of Laryngology, p. 64, 1892. 
142 . Ruault: Note sur nn signe de la suppuration des cellules ethmoidales ant. Arch, de 
Lary., p. 41, 1893. 143 . Onodi transilluminated and applied the X-ray to 1200 frontal 

sinuses and traced the outlines on the external surface. Many of these were afterward 
chiselled open. It was most interesting to note the differences in the findings by transil¬ 
lumination and the actual sizes of the cavities. Die Stirnhohle, S. 22, 1909. 



GENERAL CONSIDERATIONS. 


81 


THE RONTGEN RAY.* 

The Rontgen ray has, of later years, become a considerable 
factor in rhinology, especially in the accessory sinuses. It has 
gradually developed from merely an agent to ascertain the size 
and contour of these cavities to one of considerable worth in deter¬ 
mining their internal pathological conditions. 

The best results thus far obtained have been with the super¬ 
ficial sinuses (frontal, anterior ethmoid, and maxillary). The 
posterior ethmoid and sphenoid are not always successfully skia- 
graphed, but there is every reason to believe that these will also 
be accessible as our technique becomes more and more perfected. 
It has been supposed that the pus contained in the sinus was 
responsible for the shadow appearing on the plate. This has 
been refuted by Chisholm 144 in a number of interesting experi¬ 
ments with gelatin capsules filled with pus, blood, water, etc. 

It has also been shown that liquids from thick pus to clear 
water, after being injected into the sinus, show about the same 
shadow density. 144a ' 144b 

He reaches the conclusion that the swollen mucosa exercises 
a greater influence in causing the shadows than the character 
of free secretion in sinus. This has been substantiated by 
Albrecht, 145 who found no change in the skiagraph after syring¬ 
ing out; an antrum which was full of pus. This however, is subject 
to qualification, as the same author was able to produce a distinct 
shadow by injecting purulent secdetion into an antrum which 
previously had shown perfectly clear. It would then seem that, 
while extensive tissue changes are more amenable to skiagraphy 
than free secretion, nevertheless, both exercise a given amount of 
influence on the plates. 

Coakley 146 thinks skiagraphy may prove a valuable aid in 
determining our method of treatment, as in a small sinus we may 
expect good results from the intranasal method, while in a large 

144. Chisholm: Skiagraphy in the Diagnosis of Frontal Sinusitis. Annals of Otology, 
Rhinology and Laryngology, p. 979, 1906. 144a. Caldwell: Skiagraphy of the Accessory 

Sinuses of the Nose. Am. Quarterly of Roentgenology P. 1908. 144b. Beebe: Skiagraphic 

Diagnosis of Nasal Accessory Sinuses. Journ. Oph. Otol. and Laryng., p. 319,1915. 145. Al¬ 

brecht : Die Bedeutung der Rontgenographiefiir die Diagnoseder Nebenhohlenerkrankungen. 
Arch. f. Lary., S. 179, Bd. 20, 1908. 145a. Lemere: The Diagnosis and Treatment of Latent 

Antrum Disease. Ann. Otol. Rhin. and Laryng., p. 88, March, 1920. 145b. Ballenger, H. C.: 

A Study of One Hundred Cases of Suspected Chronic Nasal Accessory Sinus Disease with a 
Report of the X-ray Findings. Ann. Otol. Rhin. and Laryng., p. 894, 1919. 146. Coakley: 

Skiagraphy as an Aid in the Diagnosis and Treatment of Diseases of the Accessory Sinuses 
of the Nose. Ann. Otol., Rhin. and Laryn., March, p. 16, 1905. 

♦See the symposium on the use of the Roentgen ray in rhinology Burger, Gradenigo, 
Killian, Scherer. Trans. 1st Int. Lary.-Rhin. Cong., p. 229-277, Vienna, 1908. 



82 


THE ACCESSORY SINUSES OF THE NOSE. 


sinus with recesses, partial septa, eac., an external operation will 
probably be indicated. 

Lemere 145a classifies shadows on the X-ray plates as—Clear, 
Questionable, Cloudy and Opaque. In all cases, he uses four 
exposures from different angles and if the cloudiness in one or 
more sinuses is constant, the diagnosis is established. 

Ballenger, H. C. 145b says certain conditions can modify the 
density of the shadow other than products of inflammation within 
the sinus cavity such as: 

1. Asymmetry of the bones forming or containing the sinuses. 

.2. Inequalities in thickness of the bones of the face. 

3. Angle from which the exposure is taken. 

Perhaps the sign of greatest diagnostic significance is when 
blurring is noted of the sinus outlines which are faint and inclined 
to be indistinct rather than sharp and clear. 

Frontal Sinus .—In this cavity the X-ray is of inestimable 
value in determining its height and depth before operating. Not 
only is the exact size obtained, but also the presence of recesses, 
partial septa, projections, etc. We can also note if an orbital 
ethmoid cell lies posteriorly or laterally, thus minimizing the pos¬ 
sibility of confusing one of these with the posterior or meningeal 
wall of the sinus. In this way foci of suppuration may be dis¬ 
closed and promptly eradicated which otherwise might escape 
unobserved, to the subsequent detriment of the cure. 147 

The skiagraph is absolutely reliable only when the disease is 
unilateral, as when both sinuses are affected comparison cannot 
readily be made. Every case is a rule unto itself, therefore a stand¬ 
ard of comparison cannot be resorted to. As a rule, unilateral 
shadows are diagnostics for disease. Coakley 146 and Killian 147 
place the greatest reliability in them, and claimed that subsequent 
operations have always substantiated the presence of disease when¬ 
ever these shadows were distinctly outlined on the plates. 
Albrecht, 145 however, reports a case and publishes the skiagraph 
where the negative shows a distinct shadow over the frontal sinus 
which, on being opened, was found to be quite healthy. These nega¬ 
tive results are the exception, and we must expect them to accasion- 
ally appear in the natural course of events. 

In ascertaining the exact pathological condition of the sinus, 
the results have not been so successful. At the commencement of 


147. Goldman and Killian: Beitrag zur klinischen Chirurgie, Bd. 54, 1907. 



PLATE 4. 



Rontgen ray photograph showing position of sphenoid sinuses. Right sinus filled with bismuth paste 
shows dark. Left sinus light, extent shown by dotted line. 






































































GENERAL CONSIDERATIONS. 


83 


a sinus disease where the mucosa is but slightly engorged the 
results may be absolutely negative, but where extensive tissue 
changes have occurred, particularly granulation and polyp forma¬ 
tion, the shadows may be so marked that these inflammatory 
hypertrophies are often outlined in their entirety. It is often 
difficult, and even impossible, to state with certainty whether the 
shadow is due to purulent secretion or to hyperplasia of the 
mucosa. The intranasal findings should guide one in determining 
this question. It is of importance to remember that not only the 
anteroposterior, but the lateral aspect as well, should be taken 
when the frontal sinus is examined. 

Anterior Ethmoid Cells .—It seemed to have been the general 
consensus of opinion that the skiagraphical findings, so far as 
these cells are concerned, were of absolute reliability. Coakley 146 
layed especial stress upon this point, and Killian 147 went so far as 
to differentiate whether the severity of the disease was greater in 
the ethmoid or the frontal, from the comparison of the shadows. 
Albrecht 145 says that, while the results are not to be exclusively 
trusted with the frontal, nevertheless, with the ethmoid every de¬ 
pendence can be placed upon them. The assertions of these three 
authorities have invariably been borne out by their operations. 

This does not entirely coincide with our experiences during the 
past decade. In the majority of instances, reliable conclusions 
can be drawn from the shadows in the anterior ethmoidal region 
but occasionally we have been disappointed during the operation 
to find but little evidence of pathologic changes that were 
apparently so well marked on the negative. It is therefore, wise 
not to operate on these findings alone but rather to corroborate 
them by other exposures as well as to confirm the diagnosis as 
far as possible by clinical manifestations. 

Maxillary Sinus .—The same holds true here as for the frontal 
sinus; however, it is of much less importance, owing to the other 
means of diagnosis, which requires less delay or inconvenience 
(needle punctures). There are two points, however, which are of 
the utmost importance: 1. Its ability to discover the precise 
relation of the roots of the teeth to the floor of the antrum. 148 
2. The presence as well as the size and shape of neoplasms (cysts, 
sarcoma, etc.). Under the first heading we may be able to discover 
the cause of the antral suppuration and shape our treatment 
accordingly, and under the second it is often possible to ascertain, 


148. Mosher: The Use of the X-ray in Sinus Disease. Laryngoscope, p. 114, 1906, 



84 


THE ACCESSORY SINUSES OF THE NOSE. 


by the configuration and extent of the tumor, whether it is oper¬ 
able, and, if so, how much tissue it will be necessary to remove. 

Posterior Ethmoid and Sphenoid .—These cavities were con¬ 
sidered outside the limits of the X-ray, so far as diagnostic pur¬ 
poses were concerned, it was not until Spiess, 149 and later 
Pfeiffer, 150 by utilizing a new photographic position, were able to 
obtain satisfactory negatives of these deep-lying sinuses. By plac¬ 
ing the plate under the chin and the light on the vertex they were 
able to distinguish with considerable certainty the pathological con¬ 
dition of the mucosa of these cavities. Dr. G. E. Pfahler and the 
author 151 have experimented along these lines with moderately 
satisfactory results, as the condition of the sinus mucosa both before 
and after the operation was ofttimes clearly discernible. The posi¬ 
tion and relations of the sinus are clearly shown in Plates IY and V. 

However, the posterior ethmoid cells and sphenoid sinus have 
not proven as amenable to the X-ray as the more superficially 
placed sinuses. It has been definitely shown that pus, and even 
polypoid tissue 151a can be present with practically no shadow on 
the plate. 151b>151c . In reading and interpreting a plate of this region 
perhaps the most important sign is not so much the actual density, 
as the sharpness or the individual ethmoid cells as, to my mind, 
a blurring of the septa between the cells is much more indicative 
of the presence of a pathological process than the gross appear¬ 
ance of the actual shadow. 151 * Substantiation and re-sub¬ 
stantiation with successive exposures should be made before 
deciding upon extensive operative procedures either intra-nasal 
or otherwise in this region. This is, also, the opinion of 
other observers. 151e,151f,151g 

bier's hyperemia as applied to the nasal sinuses. 

This form of treatment has been applied to the nose for diag¬ 
nostic as well as therapeutic purposes. 152 ’ 153 In order to diagnose 

149. Speiss: Rontgenuntersuchungen der oberen Luftwege in Atlas, etc. Miinchen, 1909. 

150. Pfeiffer: Eine neue rontgenographische Darstellung Methode der Keilbeinhohlen. 
Arch. f. Laryn., Bd. 23, S. 420, 1910 151. Skillern and Pfahler: The Roentgen Ray as an 

Aid to the Diagnosis of Disease of the Sphenoid Sinus. Trans. Am. Lary., Rhin. and Otol. 
Soc., p. 14, 1912. 151a. Culp: Discussion. Penna. Med. Journ., p. 555, May, 1921. 151b. 

Chase: Roentgen Rays in the Diagnosis of Sinus Disease. Iowa State'Med. Iourn., Dec. 
1920. 151c. Dean: Paranasal Sinus Disease in Children. Univ. of Iowa Studies, p. 18-19, 

April ,1921. 151 d. Skillern: The Present Status of Skiagraphic interpretation as an adjunct in 

the Diagnosis of Catarrhal Affections of the Accessory Sinuses. 151 e. Levy: Nasal Accessory 
Sinus Disease. Diagnosis. Trans. Am. Laryng., Rhin. and Otol. Soc., p. 494,1920. 15 If. Boot: 
Discussion to Dutrow. Trans. Am. Acad. Ophth. and Oto-Laryng., p. 294, 1920. 15 Ig. Car- 

mody: Discussion to Dutrow. Trans. Am. Acad. Ophth. and Oto.-Laryng., p. 294, 1920. 152. 

Sondermann: Eine neue Methode zur Diagnose und Therapie der Nasenerkrankungen. 
Munch, med. Wochenschrift, Jan. 3,1905. 153. Lewis: Negative Pressure as a Therapeutic 

Agent in Disease of the Nasal Accessory Sinuses. Trans. Am. Acad. Oto-Laryng., p. 346,1908. 






PLATE 5 
























GENERAL CONSIDERATIONS. 85 

sinus disease the nose is first thoroughly lavaged in order to 
1 emove all free secretion. The bulb is then placed in one nostril 
and, while the patient continuously articulates the letter K, suction 
is applied. The rationale of this procedure is to form a negative 
pressure, thus drawing any existing secretion from the ostia of 
the sinuses. 

If a large quantity of free pus is now found in the nose, the 
diagnosis of sinus disease is made. To corroborate this finding, 
the suction should be reapplied on the following day, and, if the 
result is identical, our diagnosis is assured. 154 

With posterior ethmoid and sphenoid disease the secretion 
appears in the choana. While this method seems to be based on 
sound theoretical grounds, nevertheless, practically, it often leads 
to disappointment. Not only has this been the experience of the 
author, but of others 155 ’ 156 as well. The difficulties appear to be 
the inability of certain patients to completely close off the choana, 
and,, even when this is successful, the period of time of actual 
suction seems to be too short to draw much of the secretion out of 
the sinuses. In justice to the method, however, it must be admitted 
that in the hands of those skilled in the technic reliable diagnostic 
conclusions may be adduced. 1563 

The Tuxtxg-fork. 

It has been shown that if a tuning-fork be sounded and placed 
over the root of the nose in the median line, the sound will be heard 
in the ear corresponding to the side on which the accessory sinus 
disease is present. 15615 Whether this is due to general inflamma¬ 
tion of that side, embracing the eustachian tube, or to the purulent 
secretion and thickened mucosa forming better bone conduction, is 
not stated. In our opinion, both of these conditions may be re¬ 
garded as the essential factors. The test is most striking in 
pansinusitis of one side, although with maxillary and sphenoid 
disease positive results are obtained. Too much reliance, how¬ 
ever, should not be placed in any one of these measures, and they 
should only be used as a means to the end, to corroborate rather 
than to make the diagnosis. 

154. Sondermann: Weiterer Erfahrungen mit meinem Nasensauger. Arch. f. Lary., 
o.425. 155. Uffenorde: Kritische Bemerkungen iiber die Sondermannsche Saugmethode, 

etc. Munch, med. Wochenschrift, June 12, 1906. 156. Tilley: Trans. 1st Internat. 

Laryngo-Rhinological Congress, p. 221, Vienna, 1908. 156a. Brawley: Demonstration of 

the Suction Method in Diagnosing Sinus Disease. Laryngoscope, p. 530,1906. 156b. Glas: 

Ein neues diagnostisches Hilfsmittel zur Empyemdiagnose. Verh. Ill Inter. Laryn.-Rhin. 
Kongress, S. 296, 1911, Berlin. 




86 


THE ACCESSORY SINUSES OF THE NOSE. 


Treatment.* * 

The treatment of a given case of sinus disease depends upon a 
great many conditions. Not only the precise stadium of the dis¬ 
ease, but the individual symptoms present are the keynote upon 
which to base our therapeutic or operative efforts. Take, for 
example, two cases of acute sinusitis, one pursuing a mild course, 
the other presenting every evidence of impending cerebral or 
orbital complications. The first may be treated, expectantly, but 
with the latter prompt and energetic means must be applied. This 
will also hold good for chronic vases. On the other hand suppose 
two individuals suffered from a sinus disease of like intensity. 
One, being of neurotic temperament, suffered more than the other, 
who was of phlegmatic disposition. Here, too, different treatments 
are clearly indicated, therefore the entire question of the treat¬ 
ment of sinus disease resolves itself according to the symptoms 
presented by that particular case. In order to more clearly 
define our position, it is necessary to divide sinusitis into acute 
and chronic. 

Acute . 157 —When a patient presents himself for treatment with 
the mucous membranes of the nasal tract hyperaemic and engorged, 
headache, fever, and all the symptoms of an acute inflammation, 
we must necessarily accept that the mucosa of the sinuses are 
sympathetically affected, for such is, indeed, the case. We must 
endeavor to ascertain if this affection of the sinuses is causing 
more symptoms than would naturally be attributed to it. How 
shall we obtain this knowledge? Mere inspection by anterior 
rhinoscopy is useless, because the parts are so engorged that little 
inference can be drawn, though we find quantities of pus in the 
nasal chambers. We must put the nose in the best possible condi¬ 
tion to examine the drainage passages of the sinuses. A hot normal 
salt solution should be used and the nose thoroughly lavaged, after 
which a twenty per cent, solution of cocaine to which have been 
added a few drops of a 1/1000 solution of adrenalin, applied with a 
cotton mop until the parts have been shrunk as much as possible. 
This will often not be very much, on account of the extreme turges- 
cency of the mucosa; however, a certain amount of shrinkage 
always occurs, and this in itself will frequently occasion the 

157. See Symposium on Treatment of Acute Inflammation of the Nasal Accessory 
Sinuses, with Discussion. Hubbards al. Trans. A. L. A., p. 290, 1905. 

*Under this heading we shall not consider sinus disease complicating or accompanying 
any of the acute exanthemata, but rather a disease, per se , which is independent of any 
constitutional disturbance, and is present either by surviving the causative factor or by 
spontaneously originating in its present form. 



GENERAL CONSIDERATIONS. 


87 


greatest relief to the patient, if the sinuses are not seriously affected. 

Our next step is to ascertain whether the sinuses are secreting 
pus. In the first stage of acute sinusitis this will not occur, as the 
mucosa, though hot and turgid, is dry and almost glazed. The 
secretory stage is the next step in the process of inflammation. We 
will now accept that the primary inflammatory stage has passed 
and the residue of inflammation has settled in one or more of the 
sinuses. We note thick, creamy pus in the middle turbinate 
passage and perhaps in the olfactory fissure, which immediately 
reappears on wiping away. What is our first step in the treat¬ 
ment? Shall we confine the patient to bed? Certainly, if it is 
possible, which in all probability will not be the case. If, however, 
the headache and general disturbances are severe, this will in 
itself usually suffice to influence the patient to obey our instruc¬ 
tions. We now have two main objects to attain: (a) to keep the 
patient comfortable, and (b) to allay the inflammation. The first 
part is carried out by keeping the drainage passages as clear as 
possible. This may be accomplished in several ways. 

First by applying a strong solution of cocaine and adrenalin at 
least twice daily, and, after the parts are thoroughly contracted, 
to douche the nose with a hot saline solution—as hot as can be 
conveniently borne. This latter has two principal actions: the 
first to wash away any superfluity of cocaine, thus preventing its 
being absorbed into the general system, and secondly, to relieve the 
engorgement of the sinus mucosa. Between treatments deep in¬ 
halations through the nose every two hours of Menthol dr. 1, Tr. 
Benz. Comp. Oz. 4. Two tablespoonfuls to half pint of boiling 
water will usually suffice to keep the nose clear. The menthol and 
heat act as a stimulant and depletory on the swollen and inflamed 
mucosa, causing an increased flow of secretion with reduction of 
turgescence. In this way the drainage passages are gradually 
opened, thus allowing the pent-up secretions to escape, the sinus 
mucosa to become medicated with the vapor, and the pressure 
symptoms (headache, congestion, etc.) to be relieved. That these 
inhalations reach the sinus mucosa has been proved by the experi¬ 
ments of Caldera. 157a 

Dogs were used in which the frontal sinus was opened by removing a large 
portion of the anterior wall in one piece. Litmus paper (both red and blue) was 
placed within, the bone replaced, and the sinus closed. Ammonia or an acid was 

157a. Caldera: Experimentelle Untersuchungen iiber das Eindringen von Gasem 
Dampfen und Zerstaiibten Wasserigen Losungen in die Nasennebenhohlen. Arch. f. Laryng.* 
Bd. 28, S. 130, 1914. 



88 


THE ACCESSORY SINUSES OF THE NOSE. 


introduced by means of a special atomizer into the nose. On reopening the sinus 
the litmus paper was found to be discolored, the intensity of which depended upon 
the length of time the atomizer had been used. In further experiments he was able 
to sterilize sinuses in eight days which he had infected through the anterior wall. 
The sinuses of the control dogs remained infected. 

The nares may be lightly plugged with cotton impregnated with 
menthol. Headache is best controlled by appropriate doses of 
one of the coal-tar derivatives. 

Direct irrigation of the sinus should not be attempted, as it is 
of very doubtful benefit, and the irritation to the tissues around the 
ostium caused by the introduction of the catheter far counter¬ 
balances any good effects which might accrue from the lavage. 
The second object is to allay the inflammation. This is ac¬ 
complished both by local and general treatment. When practicable, 
the electric-light head bath, 138 consisting of several incandescent 
lights, which are made to shine directly upon the face of the 
patient, the eyes being protected, may be used to considerable 
advantage. The rationale of this method is to produce an active 
hyperaemia, which acts in the same manner as heat applied to any 
acute inflammation. Sweating is promoted to enforce the action 
of the hyperaemia by the administration of 7%-lb grs. aspirin half 
an hour before the electric-light bath. 

Negative pressure .—This form of treatment has recently been 
advocated as a therapeutic measure in sinus disease. 158a In the 
beginning I was rather impressed with its apparent possibilities 
which, unfortunately, later results failed to justify. There is no 
question that a certain amount of purulent secretion hidden in the 
nose can be brought to light, but it is extremely improbable that the 
quantity evacuated from a diseased sinus will have much influence 
upon the ultimate course of the disease especially in chronic cases. 
I have used this method where the maxillary sinus was filled with 
pus and succeeded in drawing a considerable quantity into the nose 
continuing until no more appeared, then as a control test by making 
a needle puncture and lavage, was able to obtain at least twice the 
original quantity evacuated by the suction. It probably has its 
greatest value in old ethmoid infections in which operative inter¬ 
ference is not warranted followed by thorough lavage with sterile 
saline solution. In secretion pent up within the frontal sinus, 
despite the favorable location of the ostium, evacuation is difficult 

158. Killian: DieBehandlungderentziindlichenErkrankungender Nasennebenhohlen. 
Deutsch. med. Wochenschrift, p. 721, April 20, 1911. 158a. Coffin: Non-Operative Treat¬ 

ment of the Accessory Sinuses. Laryngoscope, p. 832, Dec. 1915. 



GENERAL CONSIDERATIONS. 


89 


and for the most part unsatisfactory with suction applied as 
general negative pressure to the nares. 

Sphenoidal conditions would appear to react even less to this 
form of treatment. 

As a diagnostic means in obscure cases one may obtain their 
first clue pointing to a diseased condition of a certain sinus or 
group of ethmoid cells. 158b 

GENERAL TREATMENT. 

Calomel, one quarter grain every hour until the bowels move 
freely. Sweating is of value, provided it is profuse and carried 
out immediately. 

The usual custom of administering hot alcoholic drinks to cause diaphoresis is 
strongly to be condemned in patients suffering from sinus disease. Alcoholic invari¬ 
ably adds fuel to the fire by causing congestion of the cranial circulation. Coffee 
and tobacco act in a similar manner but in a milder degree. 

After the calomel has acted, Spts. Ammonia Arom., gtts. 
30 every hour, is given for ten hours, after which the following 
is prescribed: 

Sodii Salicyl. 

Quinia Bisulph.aa Gr. 30 

Pulv. Doveris.Gr. 15 

Misce et Fiat Capsulas No. 15. 

Sig. One capsule every two or three hours. 

This formula is not a new one, and has been used for years 
with excellent results. 

LOCAL TREATMENT. 

Ice-cold compresses over the forehead, eyes and temples. Hot 
fomentations, as advocated by some authors, may be substituted if 
the cold proves disagreeable, but better results are invariably 
secured, so far as we are concerned, with the former, and they are 
more acceptable to the patient. In this way it is usually pos¬ 
sible to cure the acute attack in from 48 to 72 hours. If, in spite 
of our treatment, the inflammation progresses and the symptoms 
become dangerous, it will be necessary to resort to a surgical 
procedure, the severity of which will depend upon the virulence 
of the disease. 

Acute exacerbations of chronic inflammation are to be treated precisely as 
though acute, otherwise the indications are somewhat different. 

158b. Discussion on Negative Pressure as a Therapeutic Measure in the Treatment of 
Sinus Disease. Coffin, Coakley. Faulkner, Dwyer, etc. Sec. on Laryng., N. Y. Acad, of 
Med. Laryngoscope, p. 882, Dec. 1918. 





90 


THE ACCESSORY SINUSES OF THE NOSE. 


Chronic Inflammation .—Tlie treatment of chronic suppuration, 
in the absence of urgent symptoms, will depend largely upon the 
individual. Teachers, selling clerks, governesses and the like, who 
depend more or less upon their employers, will find it to their dis¬ 
advantage to be continually treating and blowing their nose, as 
many people are not only prejudiced but actually fear contagion 
from them. 

In these cases something radical is demanded. On the other 
hand, individuals who are not dependent upon aesthetic niceties 
may in the absence of subjective discomforts, allow a pus-produc¬ 
ing sinus to remain neglected for years until the advancement of 
the disease forces them to seek medical attention. These, how¬ 
ever, are only generalities, and, to be precise, we must again make 
use of a hypothetical case. 

Suppose an individual applied for treatment with a mild case 
of chronic sinusitis, moderate headache, purulent discharge, etc., 
with occasional acute exacerbations. We are here dealing with a 
new condition from the acute variety, namely, permanent patho¬ 
logical tissue changes in the sinus mucosa, with occasional ob¬ 
struction to drainage. Our indications here are (1) to facilitate 
drainage, and (2) to restore the mucosa to its normal condition. 
It would be absurd to confine the patient to bed with the same 
medication as applied to the acute condition unless, of course, an 
acute exacerbation was present. Our first thought would be to 
enlarge the drainage passages to their fullest extent by clearing 
them from all hypertrophies, polypi, etc., and, if necessary, even 
to resect the septum should a marked deviation occur toward the 
diseased side. After this has been accomplished, we must direct 
our attention to the sinus itself by frequent lavages, thus cleans¬ 
ing the mucosa from all detritus. If the symptoms show improve¬ 
ment under this procedure, it should be continued ad infinitum. 
If, however, no improvement is noted, the indications for opera¬ 
tion lie with the patient himself. If he considers that he is but 
slightly inconvenienced with his affection, and fears no complica¬ 
tion, there is nothing more to be said. If, however, he demands 
to be freed from his complaint, it is our duty to perform the least 
severe operation that we deem, to the best of our knowledge, will 
suffice to bring about a cure. If any form of complication 
threatens, or we note that the disease is beginning to prey on the 
patients mind, an operation more or less radical in its effect is 
absolutely indicated. 



nerve 

Posterior 
ethmoid cell 


Optic nerve 

Posterior ethmoid 
cells 


Middle turbinate 


Maxillary sinus 


sinus 


Fig. 33.—Relation of the optic nerves to the posterior ethmoid cells. (After Onodi.) 



Sphenoid sinus 


Cerebellum 


Frontal sinus 


Posterior eth- 
id cell 


Anterior eth¬ 
moid cells 


Fig. 34.—Relations of frontal, sphenoidal and ethmoidal sinuses to the brain. 




















■ 












































































- 






































































































































































































































































































GENERAL CONSIDERATIONS. 


91 


VACCINE THERAPY. 159 ’ 160 ’ 161 

The rationale of this form of treatment is to raise the general resisting power 
of the body against the particular organism that is causing the local suppuration. 
This is accomplished as follows: Under the strictest precautions to prevent con¬ 
tamination, a sterile sound is introduced into the diseased sinus and a culture made 
on blood-smeared agar. A definite solution of a pure culture of the dead micro¬ 
organism is made and a certain amount of this injected into the patient. The 
frequency of the injections is guided largely by the symptoms. 

The value of this method in sinus disease is questionable for the following 
reasons: Acute inflammations ■ exhibit a marked tendency toward spontaneous 
recovery and if proper treatment is instituted a cure will almost certainly result. 
The majority of chronic cases are associated with mixed infection, therefore, when 
the culture is plated, how can one decide which particular organism is causing the 
suppuration? To make a vaccine of the mixed culture is unscientific and will lead 
to no satisfactory result. It will be seen then that treatment along these lines is 
largely a matter of conjecture. « 

The indications for this treatment are not many, but still there are cases in 
which it should be tried. 1. In any case of chronic sinusitis that resists the ordi¬ 
nary treatment and in which a pure culture of the infecting micro-organism is 
obtained. 2. In old chronic frontal sinusitis which did not improve under intranasal 
treatment yet 'were not of sufficient severity to ^warrant an external operation. 3. 
In cases of chronic ethmoidal suppuration which did not entirely heal after a more 
or less complete exenteration. 

In the first class much success can confidentially be expected from vaccines but 
unfortunately pure cultures in chronic cases are the exception, therefore are seldom 
met with. Under the second category, I have treated a number of cases, some of 
which finally came to an operation, others improving and disappearing from view. 
While great hopes need not be entertained, nevertheless, the patient should always 
be given the benefit of the doubt and the treatment faithfully carried out until 
improvement is noted or there can be no further question that it is unavailing. 

In the latter class I have occasionally obtained success after all local means had 
failed, but it must be remembered that this condition presents one of the most stub¬ 
born in the whole realm of sinus diseases as it is ofttimes most difficult to ascertain 
the secretory source of that omnipresent pus which invariably is present in the 
operated area. It is of no small comfort to fall back on vaccine therapy but ener¬ 
getic and persistent use of the naso-pharyngoscope and sound ultimately followed 
by the curette will bring more permanent satisfaction to both doctor and patient 
than the unlimited use of the vaccines. 

Complications. 

The great importance attached to complications resulting from 
accessory sinus disease, as shown by the investigations of recent 
years, makes it desirable to briefly review the topographical 
anatomy of these structures. (For minute relations see Anatomy 
of the Individual Sinuses). 

This consists in: 1. The relation of the sinuses to the orbital 

159. Levy: Vaccine Therapy in Rhinology and Oto-Laryngology. Ann Otol., Rhin. 
and Lary., March, p. 187, 1900. 160. Birkett and Meakins: The Value of Vaccine Treat¬ 

ment of Chronic Inflammatory Disease of the Accessory Sinuses of the Nose. Laryngoscope, 
p. 851, 1910. 161. Brawley: Auto-vaccines in Nasal Accessory Smus Infection. Laryn¬ 

goscope, p. 877, 1910. 




92 


THE ACCESSORY SINUSES OF THE NOSE. 



cavity. 2. Their relation to the optic nerve. 3. Their relation to 
the brain and adnexa. 

1. Relation to the Orbital Cavity.— The frontal Sinus adjoins 
at the junction of the superior and internal orbital walls. (Figs. 
18, 19.) The ethmoid cells form a large portion of the internal 
lateral wall (Fig.15), and the maxillary sinus is in direct relation 
with the inferior wall (Fig. 19), the roof of the sinus forming the 
floor of the orbital floor of the orbital fossa. One can easily pre¬ 
suppose how purulent material from the sinuses transgressing 
these boundaries would penetrate into the various orbital areas. 


Frontal sinus 


Ethmoid 


Optic nerve 


Pituitary body 


vein 
galli 

Anterior ethmoid 


Internal carotid 
"artery 


Fia. 35.—The veins of the orbital, ethmoidal and sphenoidal regions from above downward (after Toldt). 

2. Relation to the Optic Nerve. —It will be noted that the 
optic nerve is in close relation to the sphenoid sinus and posterior 
ethmoidal cells, only a thin layer of bone often separating the two 
structures. (Fig. 33.) 

Unfortunately no constant relation exists between these structures. Sometimes 
the optic nerve lies in close proximity to the sphenoid and one or two cells of the 
posterior ethmoid labyrinth and in other specimens several mm. of dense bone 
separate them. Onodi 162 and Loeb 163 have made extensive researches in this connec¬ 
tion. When the frontal sinus extends backwards into the lesser wing of the sphenoid 
empyema of this sinus can also affect the optic nerve. 

3. Relation to the Brain.— The posterior wall of the frontal 
sinus covers a considerable portion of the anterior lobe of the 
brain. The ethmoid cells lie directly beneath the olfactory bulbs 

162. Onodi: The Optic Nerve and the Accessory Cavities of the Nose. Ann. Otol., 

Rhin. and Lary., March, 1908. 163. H. W. Loeb: A Study of the Anatomic Relations of the 

Optic Nerve to the Accessory Cavities of the Nose. Ann. Otol., Rhin. and Lary., June, 1909. 








GENERAL CONSIDERATIONS. 


93 


and the anterior hemispheres, while the sphenoid sinus borders 
on the optic chiasm, pituitary body, internal carotid and cavernous 
sinus. (Fig. 34.) 

4. Vessels and Nerves .—The ethmoid veins and arteries course 
intracranially for a short distance. A direct communication also 
exists between the veins and lymphatics of the nasal mucosa and 
dura. It has also been shown that a considerable portion of the 
venous blood from the anterior sinuses finds its way into the 
ophthalmic vein through the supra-orbital, frontal and ethmoid 
veins. (Fig. 35.) 

CAUSES OF COMPLICATIONS. 

These may be divided into: (1) anatomical; (2) pathological. 

1. Anatomical. — a. The intimate connection between the si¬ 
nuses and neighboring organs (eye and brain) through the medium 
of the emissary veins. 

Veins of the frontal sinus anastomose with the longitudinal sinus. 

Veins of the ethmoid empty into the superior, sometimes inferior ophthalmic 
'veins. 

Veins from the ethmoid anastomose with veins of the dura. 

Veins of the sphenoid anastomose with the cavernous sinus.* Killian 164 
demonstrated connection between the vessels of the sphenoid sinus and the sheath 
of the optic nerve by means of injections of silver. 

b. Bv the presence of defects in the bony walls separating 
these structures. 

Maxillary: Defects occur in the superior or orbital wall, but 
rarely cause complications. 

Frontal: Dehiscence is not infrequently noted in the orbital 
process. When this occurs the mucosa of the sinus is in actual 
contact with the dura; when the defect is in the orbital plate the 
peri-orbital tissues impinge directly on the sinus mucous mem¬ 
brane. The posterior wall may also be defective. 

Ethmoid: Defective formation is most frequently noted in the 
lamina papyracea, thereby favoring the formation of orbital 
abscess. 

Sphenoid: Defects, when present, always occur in the superior 
or lateral walls and seem to appear more frequently than defects 
in any of the other sinuses, as shown by the numerous cases 
reported. (See Sphenoid Sinus.) 

*The minute anatomy of the circulatory system of this region is well presented by 
Holmes. Diseases of the Nasal Accessory Sinuses and Their Relation to Pathological Changes 
of the Eye and Orbit. Trans. Am. Lary., Rhin. and Otol. Soc., p. 227, 908. 

164. Killian: Die Thrombophlebitis des oberen Langsblutleiters nach Entziindung 
der Stirnhohlenschleimhaut. Zeitschr. f. Ohrenhk., No. 37, S. 343, 1900. 



94 


THE ACCESSORY SINUSES OF THE NOSE. 


2. Pathological. — a. Stagnation of secretion in the sinuses 
through obstruction to free drainage. 165 * 166 ’ 167 

Hajek 168 lays considerable stress upon this causative factor and says the 
obstruction to the free outflow need only be relative to cause threatening symptoms, 
especially if it is of long duration. 

h. Infection by an especially virulent micro-organism (strep¬ 
tococcus pyogenes). While certain micro-organisms would ap¬ 
pear to play an important role in the aetiology of complications 
following sinus disease, it must not be overlooked that other pre¬ 
disposing factors favorable to the growth and increasing viru¬ 
lence of the infecting germ are usually present; therefore, the 
complication often results from a comhinatiou of circumstances 
rather than any one given condition, for this reason: complica¬ 
tions occur much more frequently in chronic than in acute inflam¬ 
mations. 

MANNER OF OCCURRENCE. 

1. By Continuity—Dehiscence .—Gerber 169 says the purulent 
inflammation of the mucous membrane, under favorable circum¬ 
stances, is able to cause breaking down and ulceration of bone. 

2. By Contiguity. — a. Direct extension. h. Phlebitis, c. 
Lymph-channels, d. Metastases. e. Nerves. 

3. Mechanical ( pressure ).—Mucocele, pyocele, and hyper¬ 
plasias. 

1. By Continuity — Dehiscence. —When an actual defect in the 
bone is present the sinus mucosa lies in direct apposition to the 
covering of the adjoining organ (eye and brain), thus presenting 
the best possible medium for the transmission of the infection. 

2. By Contiguity. — a. Direct extension of the inflammation 
occurs in the following manner: The mucosa of the sinus breaks 
down under the purulent process with the formation of a sub¬ 
periosteal abscess and osseous necrosis. The necrotic bone allow¬ 
ing the passage of the pyogenic bacteria causes an extradural 
abscess on the cerebral side which results either in meningitis, 
cerebral abscess, or sinus thrombosis. 

Extension by contiguity may also occur with no apparent in¬ 
flammatory hone changes in the osseous walls separating the two 


165. Bryan: Chronic Empyema of the Frontal, Ethmoidal, and Sphenoidal Regions. 
Am. Journ. of Med. Sciences, p. 416, vol. 124, 1902. 166. Sicard: Complications 

endocraniennes des Sinusitis Frontales. These de Toulouse, 1905. 167. Martin: Ueber 

die Bedeutung des Verschlusses der Ostien bei entziindlichen Erkrankungen der Kief- 
erhohle. Mon. f. Ohrenhk., S. 62, 1905. 168. Hajek (6), S. 396. 169. Gerber (78), S. 158. 



GENERAL CONSIDERATIONS. 


95 


cavities, except some slight discoloration. The microscopic inves¬ 
tigations of Ortmann, 170 Hinsberg, 171 and Hajek 172 show, how¬ 
ever, that the bone in these instances was not only hemorrhagic, 
but infiltrated with numerous diplococci from the infected sinus. 
As these cases all ended fatally, the investigators were able to 
demonstrate the actual connection between the diseased sinus and 
the cerebral affection. • 

b. Phlebitis: Infection spreading through the veins is not an 
uncommon mode of transmission of a sinus inflammation. The 
infection of the larger blood-vessels (longitudinal, transverse, sig¬ 
moid, cavernous, and petrosal sinuses) is brought about indirectly 
through a phlebitis of the veins of the diseased - sinus mucosa. 
These veins perforate the bony sinus walls and empty into a 
tributary vein which goes to form one of the great cerebral venous 
sinuses. During their course from the sinus they are in intimate 
connection with the veins of the dura, and consequently are in a 
position to transmit infection to them, which would then spread 
to the meningeal structures. The sphenoid sinus is most com¬ 
monly the source of thrombophlebitic complications. This, of 
course, is due to its proximity and intimate connection with the 
cavernous sinus. The ethmoid cells would seem to follow the 
sphenoid in point of frequency of transmission of infection 
through venous channels. This is brought by the anterior and 
posterior ethmoidal veins. The frontal sinus does not furnish so 
many cases, which is perhaps due to its being situated at some 
distance from the longitudinal sinus. The maxillary sinus alone 
does not seem to have been responsible for any case of septic 
thrombophlebitis following inflammation of its mucous membrane. 

c. Lymph-channels: Regarding infection through these chan¬ 
nels, Gerber 173 says: “In those cases in which neither a direct 
continuation through the bone nor an infection through the blood¬ 
vessels can be proved, we must consider that the infection has been 
propagated through the lymph-channels.’’ 

The most convincing proof of this assertion seems to have been presented by 
Andre 174 when he demonstrated, by means of injections of Prussian blue, the 
connection between the lymphatics of the nose and those of the perimeninges. 

170. Ortmann: Der Diplokokkus pneumoniae bei eitriger Meningitis. Virchow’s 
Archiv, Bd. 120, S. 117, 1890. 171. Hinsberg: Ueber den Infec. Mechanismus. Verh. d. 

deutsch. Otol. Gesel., S. 191, 1901. .172. Hajek: Ein Beitrag zum Studium des In¬ 

fections Weges bei der rhinogenen Gehirn Komplikation. Arch. f. Lary., Bd. 18, S. 
290, 1906. 173. Gerber: Die Complikationen der Stirnhohlen. S. 187,1909. 174. Andre: 
Contribution a l’etude des Lymphatiques du Nez et des Fosses Nasales, p. 48, 1905, 
Paris. 




96 


THE ACCESSORY SINUSES OF THE NOSE. 


d. Metastases: Kulint 175 first called attention to the con¬ 
nection between the veins in the sinus mucosa and those of the 
dura. According to this author, these veins may carry the infec¬ 
tious material from the sinuses to the brain with the formation of 
a metastatic abscess without the bone showing either macroscopic 
or microscopic inflammatory changes. 

e. Along the nerves: Kay and Retzius 176 deduced from their 
experiments the possibility of infection travelling through the 
perineural sheaths of the olfactory filaments, thus causing cere¬ 
bral complications. Most, 177 on the other hand, failed to demon¬ 
strate satisfactorily the connection between the lymph-vessels of 
the nose and brain. 

3. Mechanical Pressure .—This form of complication is limited 
to the eye and results from diseases in the ethmoid cells and 
occasionally the frontal sinus. It may persist for years without 
causing permanent damage to the eye. 178 Mucocele, pyocele, 
hyperplastic ethmoiditis, and empyema with dilatation can con¬ 
tribute toward the causation of this complication. 

Both Black 179 and Stucky 180 consider that closed-in empyema 
is capable of giving rise to the most severe eye symptoms. In 
these cases the severity depends upon the combination of inflam¬ 
mation with the mechanical pressure. 


PATHOLOGICAL CONDITIONS. 

Abscess and Fistula Formations Appearing on the Face .— 
Formerly these conditions were not infrequently met with. Now, 
on account of the widened scope of our knowledge of the usual 
course of accessory sinus suppurations, these conditions are prac¬ 
tically always anticipated with appropriate measures for their 
prompt suppression. The most common of these, abscess and 
fistula formation, are those making their appearance above the 
internal angle of the eye, and are due to fronto-ethmoidal suppu¬ 
ration. Infra-orbital abscess has not infrequently been reported 


175. Kuhnt (98), S. 559. 176. Kay and Retzius: Studien in der Anatomie des Ner- 
vensystems. S.217, Stockholm, 1875. 177. Most: Topograph d. Lymphgefass. d. Kopfes. 
S. 91, 1906, Berlin. 178. Risley: Displacements of the Eyeball by Disease of the Frontai 
and Ethmoidal Sinuses. Intemat. Med. Magazine, vol. 9, p. 732, 1900. 179. Black" 

Frontal Sinusitis as an Etiological Factor in Acute Retrobulbar Neuritis New York 
Med. Journ June 2/ p. 1126, 1906. 180. Stucky: The Relation of the Pathological 

Condition of the Nose and Accessory Sinuses to the Visual Apparatus. Laryngoscope, 



GENERAL CONSIDERATIONS. 


97 


due to maxillary empyema. 181 * 182 Orbital abscess resulting from 
sinus disease is usually the result of ethmoidal suppuration. 

Orbital Complications . 184 " 186 — 1 . Disturbances in the circula¬ 
tion. 2. Intoxication. 3. Purulent inflammation. 4. Pressure 
symptoms. 

1. Disturbances in the circulation consist in: a. Hyperemia. 
b. Thrombosis of the vena centralis retinis (blindness), c. 
Thrombosis of the cavernous sinus. 

2. Intoxication: This form affects the optic nerve and is par¬ 
ticularly associated with sphenoidal empyema, in which there 
always exists more or less obstruction. 

3. Purulent inflammation: The extension of abscess formation 
without the mediary of micro-organismal activity is accomplished 
in the following manner: The continual apposition of the purulent 
secretion results in maceration of the epithelium, which gradually 
pervades the entire mucosa until it becomes, in certain areas, 
loose on the underlying bone. The purulent material, thus coming 
in direct contact with the bone, slowly infiltrates through the 
canaliculae and Haversian canals (possibly with the aid of the 
blood- and lymph-vessels) and eventually reaches the periosteum 
of the opposite side. From here on but little resistance is opposed 
to the spread of the infection. 

The course of the infection from the sinuses is sometimes effectually barred 
from entering the eye by the orbital periosteum in the following manner: The 
periosteum becomes thickened from repeated irritation, thus preventing further 
entry of the infection. The purulent material finding its passage barred forms a 
periosteal abscess and is evacuated at the corner of the eye. 183 

It will be noted that Kuhnt mentions particularly “ repeated inflammation.” 
This can only result from long and continued irritation. Therefore, should a 
severe attack primarily occur it is more than probable that the inflammation would 
penetrate the orbital periosteum with the formation of an orbital phlegmon. 

Kuhnt divides the orbital complications into the following 
category: 

1. Inflammatory: a. Affections of the conjunctiva and cornea. 
b. Affections of the uveal tract, c. Affections of the retina and 
optic nerve. 


181. Harlan: Exophthalmos due to Disease of the Maxillary Antrum. Ophthal. 
Record, p. 92, 1898. 182. Ogchu: Orbitalphlegmon following Empyema of the Maxillary 
Sinus. Annals, of Ophthal., p, 713, 1903. 183. Kuhnt (98), S. 109. See especially— 184. 
Kuhnt: Beziehungen zwischen Nasen und Augenleiden. Verh. 1st Internat. Laryng. 
Kongress, Wien, S. 109, 1908. 185. Eversbusch: Graefe-Saemisch Handbuch, II Teil, IX 

Band, Kap. 16, 1903. 186. Ring: G.O. Association of Ocular and Nasal Sinus Disease. 

Annals Otol., Rhinol. and Laryngol., March, 1918. 



98 THE ACCESSORY SINUSES OF THE NOSE. 

2. Functional: a. Muscular asthenopia, b . Loss of accom¬ 
modation. 

3. Mechanical: a. Disturbance of the bulbar mobility, b. Irri¬ 
tation of the optic nerve through pressure. 

Disturbances of vision practically always result from posterior 
ethmoid and sphenoid disease. 

Cerebral Complications: 1. Various forms of meningitis. 2. 
Extradural, intradural, and cerebral abscess. 3. Thrombophle¬ 
bitis of the venus sinuses. 

Orbital and cerebral complications are often more or less 
dependent upon one another, being frequently present in the same 
case; thus, an orbital abscess can cause meningitis either by direct 
transmission of the inflammation through the optic foramen or by 
thrombosis of the ophthalmic vein. On the other hand, a low- 
grade form of meningitis from the sphenoid sinus can cause 
primary phlebitis of the cavernous sinus, which in turn causes 
secondary thrombosis of the orbital veins. 

Gradle 186a does not believe that an intimate anatomic relation¬ 
ship between the optic nerve and the sinus is necessary as an etio- 
logic factor in disturbances of vision for the following reasons. 
The infection finds its way from the sinus mucosa to the periosteal 
lining of the orbit through the emissary veins and lymph channels. 
The optic nerve is now affected by direct extension of the inflam¬ 
matory process which causes a pressure (from swelling) upon the 
periphery of the optic nerve with the consequent enlargement of 
the blind spot. Should the central vein of Vossius become 
involved through further spread of the infection (toxic) causing 
edema with pressure upon the adjoining nerve bundles, a central 
scotoma will result. It is thus shown the pathological process is 
transmitted through the soft tissues, osseus involvement not being 
essential. From observation of a considerable number of cases, 
I am strongly inclined toward this theory of the causation of 
ocular complications. 

Symptoms.— Orbital ; 187 - 190 1. Those caused by inflammation. 

2. Those caused by pressure. 3. Those caused by toxins. 

1. Those Caused by Inf animation .—The first intimation that 

186a. Gradle: The Blind Spot. Annals of Ophthalmology, Vol. 24, 1915. 187. Ziem : 

Beziehungen zwischen Augen und Nasenerkrankungen. Mon. f. Ohrenhk., S. 231,261,1893. 
188. Posey: The Ocular Symptoms of Affections of the Accessory Sinuses of the Nose. Journ. 
Am. Med. Assn., Sept. 9, 1905. 189. Fish: On the Frequency of Blindness Due to an Affec¬ 
tion of the Accessory Sinuses. Am. Journ. of Surgery, Sept., p. 257, 1906. 190. Cohen and 

Reinking: Beitrage zur Klinik der orbitalen Komplikationen bei Erkrankungen derNeben- 
hohlen der Nase. Beitrage zur Augenheilkunde, 78 Heft., 1911. 



GENERAL CONSIDERATIONS. 


99 


the orbital contents have become infected through the sinus disease 
is often a slight, persistent oedema of the upper lid which is un¬ 
accompanied with any of the usual signs of inflammation (hyper¬ 
emia, pain, etc.). If the sinus affection is recognized and properly 
treated at this stage, resolution is practically always effected, as 
this inflammation is confined to the periosteum. Should come on the 
other hand, the infection continue, an orbital abscess will result, 
the severity of the symptoms depending upon the degree and 
virulency of the infection. 190 * 

If the periosteum offers sufficient resistence the pus will burrow beneath it, 
forming a fistulous tract either forward, extending to the inner angle of the eye, 
or backward as far as the optic nerve. 191 

Sometimes the abscess formation, particularly in chronic 
cases, is very gradual. Under these circumstances the subjective 
symptoms may be trivial, perhaps at first only a diplopia being 
present. 192 In making the diagnosis of orbital abscess resulting 
from sinus affection one must not only be convinced that sinus 
disease exists, but must consider carefully the seat of the purulent 
accumulation. With frontal sinus empyema one would expect to 
find the abscess in the anterior portion of the orbit; with posterior 
ethmoid or sphenoid suppuration the abscess would be situated 
posteriorly. The direction of the dislocation of the bulb will often 
be of service in differentiating these conditions. 

In phlegmon of the orbit the frontal sinus should always be 
explored. Frontal sinusitis may induce a phlegmon by the infec¬ 
tion spreading by veins and lymphatics through apparently 
healthy bone. The sphenoid is rarely ever responsible. 

2. Those caused by { Pressure (Mechanical) . 193 —Closed em¬ 
pyema (pyocele) and mucocele, by reason of their slow and 
gradual growth, will frequently dislocate the bulb without causing 
inflammatory symptoms. The direction of this dislocation is down¬ 
ward and outward from the frontal sinus; if the accumulation 
is in the ethmoid, the direction is forward, downward, and out¬ 
ward. Vail 193a has reported four cases of exophthalmos from 
abscess of the accessory sinuses, each being a type for a different 
sinus. When the pressure attacks the optic nerve, disturbances 

190a. Rollet and Bussy: Phlegmons de I/Orbite et Phlegmons de L’Oeil. Lyon Med¬ 
ical, p. 965,1920. 191. Hoffman: Die Beziehungen der Entziindlichen Orbital Erkrankungen 

zu den Erkrankungen der Nebenhohlen der Nase. Verh. d. Vereins deutsch. Lary. Gesell.. 
S. 91, 1907. 192. Brown: Empyema of Maxillary Sinus, etc. New York Med. Record, 

April 1.1893. 193. Birsch Hirschfeld: Exopthalmus bei Ektasie der Nebenhohlen der Orbita. 

Graefe Saemisch. 2nd Teil, 9th Band, 13th Kap., 1907. 193a. Vail: Types of Orbital Abscess 

and Exopthalmus Due to Intranasal Suppurative Processes. Laryngoscope, May, 1919. 





100 


THE ACCESSORY SINUSES OF THE NOSE. 


in sight occur, such as decrease in the extent of the field of vision, 
amblyopia, and even optic nerve atrophy. 194 

I have often been impressed with the constant occurrence of one symptom in 
patients suffering from optic athrophy associated with sinus disease. This is the 
intermittent paroxysms of excruciating headache. The type of this pain seems to 
be different from that ordinarily met with in sinus affections in that it is deep- 
seated and often comes on during the night. As the atrophy progresses and the 
patient becomes blind the headache undergoes great amelioration. 


Changes in the cornea 195 and uveal tract, 196-198 as well as the 
choroid, 199 retina, 201 and iris, 200 have been reported by the 
ophthalmologists. 

Retrobulbar neuritis, 202 which may result in atrophy and loss 
of vision, 203 also occurs as a complication of accessory sinus dis¬ 
ease. One of the most notable early signs of posterior sinus 
disease is an enlargement of the blind spot. 203a The presence of 
this symptom is almost pathognomonic of posterior ethmoid or 
sphenoid empyema. An unusual case of bi-temporal hemianopsia 
from acute inflammation of these sinuses which was confirmed by 
partial recovery after operation has recently been reported. 203b 

Those cases of purely rhinological origin occur usually from inflammation of 
the sphenoid sinus or posterior ethmoid cells. It is not essential that those structures 
be purulently affected, for it is not infrequently found on operation that outside of 
an intense hyperaemia nothing further of a pathological nature is present in this 
immediate vicinity. This is readily explained when one considers that the greatest 
etiological factor is the circulatory disturbance of the nerve due to the pressure of 
the swollen mucosa and exudate, toxicity playing a secondary role. As a proof of 
this, the many cases of spontaneous disappearance of the visual disturbances after 
resection of the anterior portion of the middle turbinate, bulla ethmoidalis, anterior 
ethmoid cells, etc., thus relieving the congestion, may be cited. In all cases, there¬ 
fore, of acute retrobulbar neuritis in which the etiology is obscure, despite lack of 
evidence on rhinological examination, the sinuses on the affected side (posterior 
ethmoidal and sphenoid) and, if this fails, those of the opposite side should be 
opened and explored as a routine procedure. 204 

3. Those Caused by toxins. Muscular Asthenopia and Loss of 
Accommodation: The optic nerve seems to be particularly sus- 


1Chiariu. Marschik: Zusammenhangder Erkrankungen der Orbita und der Neben- 
hohlen der Nase. Medizin klinik No. 16, 1908. 195. Gradle: On Intra-ocular Disease 

i 0n ,^? 1Se ™ e ^ ^ asa l Sinuses. Ophthalmology, vol. 5, p. 400, April. 1909. 

iyo. //iem (187). 197. Posey: Some Ophthalmological Phases of Diseases of the Accessory 

,n n c US ^ ? f ,JS2x No ?2« i ourn ; of E y e - Ear : N ose and Throat Dis., March and April, 1905. 
198. rish (189). 1^9. Broeckaert: Opacities des corps vitre, etc. Revue hebd, de laryn., 

i t n in/Y 7 ^ ason: Irdis Due to Diseases of the Sinuses. Iowa Med. Journ., Dec. 

15, 1907. 201. Rosenberg u. Baum: Erkrank. der Nasennebenhohlen u. d. Auges. Zeitschr. 

f. Larv., Bd. 1, S.441, 1909. 202. Fish: A Studv of 36 Successive Cases of Optic Neuritis. 
ion? * 1 oA C f SS SS r 5?? 8e Present 26 Times. Journ. Lary., Rhin. and Otol., vol. 22, p. 442, 
f Ku ii Jibber retrobulbare Neuritis infolge von Nebenhohlenerkrankungen. Zeit. 

. Ihrenhk., Bd. 63,S. 231,1911. 203a. Vau der Hoove: Vergrosserung des blinden Fleckes 
TVTU Hohsvmptomfur die Erkennung der Sehnervenedtrankung bei Erkrankung der hinteren 
Nebenhohlen der Nase. Arch. f. Augenheilk., vol. 67, S. 101, 1910. 203b. Conlon: Bitem- 

r? r u!v, i m ^ P ue to Acute Suppuration of the Posterior Nasal Sinuses. Am. Journ. of 
Ophthal., Feb. 1019. 204. E. Wertheim: Ueber die Beziehungen der neuritis optica retro- 

bu I bans zu den Nebenhohlenerkrankungen der Nase. Arch. f. Larvng.. Bd. 27, S. 162,1913. 




GENERAL CONSIDERATIONS. 101 

ceptible to the action of toxins, and limitation of the visual field is 
often the first symptom of a sinusitis. That this action was toxic 
is proved by the rapid return to normal of the visual disturbances 
after a radical operation. 

This is probably due to the fact that the optic nerve partakes more of the char¬ 
acteristics of a central intra-cerebral cord than a true nerve, having coverings 
similar to those of the brain and spinal cord; therefore, it is more prone to become 
affected by toxins than the ordinary motor or sensory nerve trunk. 

Dull pain and eye-ache is a frequent symptom of early involve¬ 
ment, and can be due to any of these causes. 205 

Cerebral: The general symptoms of these complications differ 
in no way from those of similar pathological changes due to other 
causes. They are the usual symptomatology of cerebral affections, 
depending upon the particular lesion, as intense headache, fever, 
slowing of the pulse, dizziness, vomiting, delirium, and convul¬ 
sions. Physical manifestations are present in the milder cases 
and during the periods of remission of consciousness. 

When either a cerebral or an orbital complication is about to 
take place in an individual suffering from sinus disease, a change 
occurs in the general condition.* * This change is usually ushered 
in with a fever and its attending phenomena. Swelling of the facial 
or orbital walls of the sinus almost invariably are present and are 
of great significance for beginning meningeal involvement. The 
height of the fever is in direct ratio to the violence of the com¬ 
plication. The local sinus inflammation seems to be particularly 
accentuated. Local pain and headache, while conspicuous, never¬ 
theless, as indications for the extent of the pathological process 
are wholly unreliable. After a period lasting from several hours 
to days, the complication will manifest itself in the adjoining 
organ suddenly or slowly, as the case may be. 

A peculiar forerunner of an impending cerebral complication is that condition 
which C. Jackson 206 calls meningismus. I have in a number of instances been able 
to demonstrate this to my entire satisfaction. In several cases the cerebral complica¬ 
tion was aborted by a timely operation; in others it followed despite my most 
earnest endeavors to the contrary. 

Empyema of the Accessory Sinuses in Children. —Children 
seem to be particularly susceptible to colds, especially that form 
known as rhinitis; why, then, do not their sinuses more often be- 

205. Hastings: Ocular Symptoms of Nasal Origin. Report of a Case of Retrobulbar 
Neuritis and Other Illustrative Cases. Ann. Otol., Rhin. and Laryn., Sept., p. 420, 1906. 
206. Chev. Jackson: Meningism as Distinguished from Meningitis. Journ. Am. Med. Assn., 
Mar. 3. p. 1265. 1907. 

*The non-inflammatory conditions are not here considered. 







102 


THE ACCESSORY SINUSES OF THE NOSE. 

come affected If The answer to this question will be apparent 
if one recalls that the sinuses, with the exception of the ethmoid, 
are hardly more than indentations in the cancellous hone during 
the early years of childhood. However, that sinus empyema does 
occasionally occur in children is unquestionable, as up to the 
present time many well authenticated cases have been reported. 
The disease in children does not appear to be a sequel of a general 
respiratory inflammation or a separate entity, as in adults, but 
when it does occur rather to be dependent on and concomitant with 
certain of the general infectious diseases. 20 ** Chief among these 
are scarlet fever, diptheria, measles and bronchopneumonia. 
Chronic bronchitis in children may also be due to an empyema of 
the maxillary antrum which has been overlooked. Mills found 
such to be the case in children ranging from six to fourteen years 
old in whom the cough speedily subsided after the purulent secre¬ 
tion was cleared from the maxillary sinuses. 206b These apply more 
to children after the second year, for in the new born direct 
infections are most commonly the setiological factor and involve 
the antrum, while in children of later years the ethmoid cells 
appear to be the seat of predilection. 

Cases of maxillary sinus empyema in children ranging from three weeks of age 
upwards have from time to time been reported. 207 208 209 210 In many of these the 
disease manifested itself through abscess and fistula formation in the infra-orbital 
region. A number of investigators have 210 211 212 called attention to the simulation 
of acute idiopathic osteomyelitis to empyema in children, and warn against the 
confusion of these separate and distinct affections. Kelly 213 considers the effection 
an acute ostitis which, contrary to the usual opinion, takes its origin from the 
alveous and by infecting the dental sac spreads upward until more or less of the 
entire superior maxilla is involved. I rather agree with this author that some 
local bone infection (not necessarily tubercular), was responsible for the abscess 
formation; however, some previous illness may have contributed to this local infec¬ 
tion, for it is a well established fact that the exanthemata 30 in children particularly 
predisposed to osseous necrosis and fistula formation. Coffin 208 reports three cases 
of suppurative etlimoiditis in children nine and ten years of age. 

fPanzer, in a material of 15,000 subjects in the Vienna Hospital, claimed to have found 
only seven cases. Buffalo Med. Journ., vol. 44, p. 444, 1905. 

206a. Schlemmer: Die NebenhohlenerkrankungeninKindesalter. Archiv. f. Laryng., 
Bd. 28, S. 60, 1913. 206b. Mills: Bronchitis due to Empyema of the Maxillary Antrum. 

Med. Journ. of Australia. May, 22,1920. 207. Canestro: Entzundung der Highmoreshohle 

bei Neugeborenen. Archiv. f. Lary., Bd. 25, S. 492, 1911. 208. Coffin: (6 months) Sinus¬ 
itis in Children. Laryngoscope, p. 884, 1904. 209. Mayer: (30 months) Empyema of the 

Antrum of Highmore in Young Infants. Trans. Am. Lary. Assn., p. 54, 1901. 210. Schmie- 

gelow: Ueber akute Osteomyelitis des Oberkiers. Arch. f. Lary., Bd. 5, S. 115, 1896. 211. 
Rudaux: Empyeme du sinus maxillaire ches un enfant de trois semaines. Ann. d. Mai. du 
Larynx, Tome xxi, vol. 2, p. 229,1895. 212 . Lichtwitz: Akute Osteomyelitis des Oberkiefers 

ein sogennantes klassisches Empyem dar Ilighmorshohle simulierend. Arch. f. Larv., Bd. 7, 
S. 439, 1898. 213. Brawn Kelly: The so-called “Empyeme of the Antrum of Highmore 
Infants” (Osteomyelitis of the Superior Maxilla). Edinburgh Medical Journal, Oct., 1904. 



GENERAL CONSIDERATIONS. 


103 


The recognition of inflammation in the sinuses of a child is 
more difficult than in the adult on account of the obscurity of the 
symptoms, and it is unusual to have a single sinus involved to the 
exclusion of the others on the same side. 213b The diagnosis is 
greatly facilitated by the X-ray, as a careful study of the plates 
will often enable one to differentiate the healthy from the 
diseased tissues. 2130 

The nasopharyngoscope also offers great advantages in ex¬ 
amining the posterior ethmoid and sphenoid structures in young 
children and will often disclose pathological conditions that could 
not be demonstrated by any other method. 213d Before it is used, 
the necessity of thoroughly cleaning the nostril of secretion and 
shrinking the mucous membrane is of course obvious. It may also 
be necessary to have the aid of a strong nurse or an assistant to 
control the young infant or recalcitrant child, but it is well worth 
the trouble for the gained information. In suspected maxillary 
sinus empyema it is quite feasible to make use of an exploratory 
needle puncture under the inferior turbinate. In this manner 
Hajek 213e was able to diagnose and cure four cases in children be¬ 
tween five and twelve years of age. The puncture needle as a diag¬ 
nostic means in children does not especially appeal to me, despite 
Hajek’s 2136 good results in children as young as 5 years. When 
one considers the small size of the antrum even should pus appear 
on irrigation through the needle, it would be difficult to determine 
whether or not the pus really was secreted by the antral mucosa. 

Dean 213f has had considerable success in passing a trocar into 
the antrum through the antro-meatal wall, under general anaesthe¬ 
sia, and through this a long blunt pointed needle attached to a glass 
syringe. One to three c.c. of sterile normal salt solution was 
thrown into the antrum, then drawn out and examined for pus, 
mucous and bacteria. 

Diagnosis: Sinus disease in children takes one of two forms, 
either distinctly acute or distinctly chronic. The typical acute 
case (much the rarer) begins with a general malaise which is soon 
followed by some fever. One side of the face becomes slightly 
congested cedematous with more or less nasal obstruction on the 


213b. Skillern: The Diagnosis and Treatment of Sinusitis of Infants. Journ. Am Med. 
Assn., Sept. 15, 1917. 213c. Oppenheimer: Some Remarks on Disease of the Nasal Access¬ 
ory Cavities of Children. Journ. Amer. Med. Assn., p. 656, Aug. 30, 1919. 213d. Oppen¬ 

heimer: The Surgical Anatomy, Diagnosis and Treatment of the Tr ; fl a^atory AfTections 
of the Nasal Accessory Sinuses in Children. Archiv. of Pediatrics p. 4,1913 ^ 13 e. liajek. 

Lehrbuch, S. 11. 213f. Dean and Armstrong: Smus Disease in Infants and Young Children, 

Trans. Am. Laryng., Rhin. and Otol. Soc., 1918. 








104 


THE ACCESSORY SINUSES OF THE NOSE. 


affected side. The infra-orbital swelling increases until fluctua¬ 
tion appears or a purulent discharge occurs from the nose or both 
appear simultaneously according to the severity of the case. The 
acute symptoms may then subside and chronicity develops or may 
require surgical intervention as the case may be. 

The chronic form often has an insidious onset possibly after 
repeated attacks of coryza so that attention is drawn to the condi¬ 
tion more from the repeated or continuous attacks of cold in the 
head rather than a definite sinus, disease. The symptoms while 
marked are rather mild in contra-distinction to the typical acute 
form. Nasal discharge appears to be the predominant one and 
is usually bilateral, thus tending to confuse the condition with a 
common rhinitis. 

During operation for tonsils and adenoids, in a case where 
sinus disease has been totally unsuspected, the ether causing a 
congestion of the mucosa brings on a profuse nasal discharge 
entirely out of proportion to that normally noted. Subsequent 
examination discloses the presence of a sinus infection. 

Post nasal discharge is also almost invariably present but can 
only be demonstrated by repeated examination through the mouth. 
Gagging produced by the tongue depressor will bring secretion 
down from the naso-pharynx appearing behind the vulva. 

Frequent attacks of sneezing is almost pathognomic of sinus 
involvement in children and should be so considered in the event 
of its repeated occurrence. 

Headache. The importance of this symptom in infants and 
young children is not proportionate as in adults as far as indi¬ 
cating the presence of a sinusitis is concerned. As a symptom it 
is inconstant but the older the child the more successful one is in 
its elicitation. 213 * f As the sinus assumes its development (from 
nine years of age) just so m proportion can we expect to find the 
typical sinus headache and in contra-distinction the younger the 
patient the less likelyhood of its occurrence. Of course any form 
of closed in empyema is excluded. 

General symptoms. A child with chronic form of sinusitis is 
distinctly unwell. There is a change in the disposition, a loss of 
appetite, a certain amount of fever such as is found in infected 
glands or any form of focal infection, listlessness and sallow skin. 

213*. Dean: Para-nasal Sinus Disease in Children. Univ. of Iowa Studies, vol. 2, No. 1, 
April, 1921. 213f. Byfield: Chronic Nasal Sinus Infection in Childhood from the Viewpoint 

of the Pediatrist. Univ. of Iowa Studies, vol. 2, No. 1, April 15, 1921. 







Palate bone 


Fig. 3S.—Various structures entering into the base of the maxillary sinus. 




























Fig. 39. —Section through anterior portion of the antrum looking forward. R. Ridge for transmission of 

infra-orbital vessels and nerve. 



Fig. 40. —Section through the anterior third of the antrum. Small ethmoidal cell situated in the 

superior angle. 



FiG. 41.—Nasal packing forceps. 



























GENERAL CONSIDERATIONS. 


105 


TREATMENT. 

Conservative .—In the beginning of an attack it can almost 
always be brought under control by general and conservative 
intra-nasal treatment, particularly when the symptoms point to 
frontal or anterior ethmoidal trouble (scarlet fever being ex¬ 
cluded). This is also the experience of some of our foreign col¬ 
leagues. Calomel, one-tenth grain, with sodium bicarbonate, 1 
grain, should be given every hour until free purgation is produced. 
Calomel has a peculiarly beneficial effect with children and as a 
general eliminant cannot be surpassed. Locally a cleansing 
douche of physiologic sodium chlorid solution several times 
daily followed by a spray of 1/20,000 adrenalin solution will suffice 
to keep the nose free. 

Vaccines .—I have found these more useful in this class of sinus 
disease than in any other. My experience has been confined mostly 
to those commonly carried in stock, although on one or two 
occasions these preparations have failed and the subsequent use 
of the autogenous vaccine brought about a cure. 

The tonsils and adenoids should be removed in all cases as it 
has been shown that at least eighty per cent, of sinus cases in 
infants and children recover after this procedure. 

Surgical .—There is one thing marked in these cases; it is that 
the indications for surgical interference are very definite. A case 
is either one for conservative treatment or for operative pro¬ 
cedure. That boundary line so perplexing in the adult is, at least 
as far as I know, not seen in children, and when operation is indi¬ 
cated, it should be performed at once. In no other class of patients 
does the disease progress so fast as in the young child, and often it 
is so advanced, when coming under our observation, that a most 
extensive and radical operation is required to save the child’s 
life, not to speak of a cure of the affection. When we observe a 
child with a deformed face from a sinus abscess about to rupture, 
with exophthalmos, swelling of the lids, oedema and a redness 
which together constitute a hideous deformity, one cannot help but 
feel, as Coffin 2138 states, that there existed a previous stage 
during which proper treatment would have prevented the present 
serious condition. 

21 3g. Coffin: Empyema of the Nasal Accessory Sinuses in Children under Fourteen 

Years of Age, Tr. Am. Laryngol Assn., p. Ill, 1914. 












106 


THE ACCESSORY SINUSES OF THE NOSE. 


When such a case comes to operation, a simple conservative 
procedure is usually of no avail. Chiari and Marschick, 213h by the 
removal of the anterior end of the middle turbinate and anti¬ 
phlogistic measures, were able to bring only 25 per cent, of the 
cases to the healing stage. Dean, 213i however, before operating 
upon the mixillary antrum of children rotates the inferior turbi¬ 
nate inward and upward with a pair of blunt forceps, thus expos¬ 
ing the inferior meatus as well as if the turbinate had been 
resected. The hypertrophied and necrotic areas in the antrum are 
now curetted, particular attention being given to the floor The 
turbinate is replaced in position without any apparent ill effect 
from being turned upward. We should first try the intranasal ex¬ 
enteration of the diseased ethmoid cells and maxillary antrum 
with subsequent applications of an organic silver compound and 
administration of appropriate vaccines. Intranasal operations 
alone, however, are usually unavailing if much redness and swell¬ 
ing have appeared externally in the region of the eye. If it is 
necessary to make an external opening, even though a fistula had 
already formed, the incision should only be large enough for 
drainage. The bulk of the work should be intranasal. I have 
never seen a patient who did not recover under this form of 
treatment. Regarding the maxillary sinus, the Caldwell-Luc 
or any similar procedure through the canine fossa should never 
be resorted to on account of the destruction of the teeth germs 
which must necessarily follow. 

If the antrum alone is affected, any thorough intranasal opera¬ 
tion will give as good results as one can hope for from any of the 
more radical or external methods. 


NebeSi^ 

Sinuses in Infants and Young Children etc. Ann. Otol. Rhin. and Laryng., jine l91 8 





PART II. 

MAXILLARY SINUS. 


ANATOMY. 

The maxillary sinus may be likened unto a pyramid, with the lat¬ 
eral wall of the nose forming the base, the apex being at the junc¬ 
tion of the malar bone with the superior maxillary. (Figs. 36, 37.) 
This would give us three sides, i.e., a superior, an anterior, and a 
posterior, and a base. These sides or walls constitute the limi¬ 
tations of the sinus proper, so that the boundaries of the maxillary 
sinus would be: above, by the orbital plate of the superior max¬ 
illary; anteriorly, by the canine fossa, and, posteriorly, by the 
pterygomaxillary fossa. The base, as has already been stated, is 
formed by those constituents which enter into the formation of 
the lateral nasal wall, viz., maxillary process of inferior turbinate, 
portion of palate bone, uncinate process, lamella of ethmoidal 
bulla, and the pars membranacea. (Fig. 38.) 

The alveolar process cannot be considered a wall, as it only forms the inferior 
border of the fossa which is formed by the junction of the anterior wall and 
base (lateral nasal wall). 

The size and capacity of the sinus depend, as in other accessory 
sinuses, largely on the amount of bone reabsorption which has 
occurred, although the sex and age of the individual of course 
exercise no little influence ; thus one would naturally find larger 
sinuses in the male than in the female, or in the aged rather than 
in the young. 

The dimensions of an average maxillary sinus would be: Height 3.5 cm. 
(about IV 2 inches), breadth 2.5 cm. (1 inch), and depth 3.2 cm. (1J4 inches). 
These relations are seldom constant. The normal capacity may be put at about 
10 c.c _ 12 c.c. in woman and 16 c.c. _ 18 c.c. in man. 

The shape, relation, and position of the sinus depend more 
particularly upon the peculiar construction of the individual than 
upon reabsorption. This phase of the subject will, however, be 
deferred until the anomalies of the maxillary sinus are considered. 

RELATIVE IMPORTANCE OF THE WALLS. 

The most important wall, from the point of view of the rhin- 
ologist, is the nasal, and for two reasons: 1. Because it contains 

107 






108 


THE ACCESSORY SINUSES OF THE NOSE. 


the sole opening into the sinus and is the first to show pathological 
changes when the sinus is affected. 2. It is the thinnest and pre¬ 
sents the easiest mode of attacking the cavity, either for diagnostic 
or therapeutic (conservative or radical) purposes. 

The anterior or wall of the canine fossa is next in importance, 
as radical operative procedures are usually made through this 
structure. It can range from the thinness of ordinary writing 
paper to several millimeters in thickness, depending upon the 
age and the construction of the facial bones. Reabsorption can 
become so extensive in the aged that a portion of this wall may 
entirely lose its osseous tissue and be formed by the periosteum 
and mucous membrane of sinus, as a specimen of the author’s has 
demonstrated. The thinnest portion of this wall is directly in the 
centre of the canine fossa, and is the point of election for opening 
with the chisel in the external radical operation. 

The infra-orbital foramen lies in this wall close to its upper 
margin directly over the canine fossa. This fact must always be 
borne in mind when performing extensive resections, as in the 
external radical operation. 

The posterior or sphenomaxillary wall is usually of even and 
constant thickness, and presents little of importance to the rhin- 
ologist. The superior or orbital plate is of interest on account 
of the dehiscences which it frequently presents, 214 " 215 and because 
of its close proximity to the orbit, as well as the fact that the infra¬ 
orbital vessels and nerves are practically enclosed in its walls. 

The infra-orbital canal which transmits these structures begins 
on the superior surface, about half way back, and ends in the 
infra-orbital foramen. Not infrequently it presents a well 
marked ridge in the roof of the sinus, causing a more or less 
marked infra-orbital recess within the cavity. 216 (Fig. 39.) A 
separate cell is sometimes present directly below the orbital wall 
at its anterosuperior angle. (Fig. 40.) This structure is an 
anomalously-situated ethmoid cell, first described by Logan Tur¬ 
ner, 217 who termed it a maxillo-ethmoid cell. This cell can only 
exist when the antral roof is situated higher than the ethmoidal 


214. Zuckerkandl (45), S. 286. 215. Onodi: Die Dehiscenzen der Nebenhohlen der 
' Lary., Bd., 15 S. 62, 1903. 216. Cryer: Internal Anotomy of Face, p. 
tt v yU i ; n l' Logan Turner : Accessory Sinuses of the Nose, p. 7, 1901. 218. Kanasuei: 
Ueber die Dehiscenzen der Kieferhohle. Berl. klin. Woch., Bd. 45, S. 1405, 1908. 



MAXILLARY SINUS. 


109 


bulla. Next to the nasal, the orbital is the thinnest of the bound¬ 
ary walls, particularly in that portion which is occupied by the 
infra-orbital canal. 

CONGENITAL DEFECTS OR DEHISCENCES. 

Dehiscences in the walls of the maxillary sinus are rare, 
although several instances have been reported. 214-218 The prin¬ 
cipal cause appears to be atrophy from old age, and occurs by con¬ 
tinual reabsorption of the walls until the osseous structure entirely 
disappears from one or more places. Congenital dehiscence is 
prone to occur along the line of the infra-orbital canal. When 
defects occur in the lamina papyracea, the orbital plate of the 
superior maxilla is very apt to share in the defective formation. 

Zuckerkandl 214 says dehiscence in the sinus walls occurs in three ways: 
1. Reabsorption due to old age (most frequent). 2. From deep lying channels for 
blood-vessels. 3. Defect in the formation of the bone (anomalous). The most 
frequent situation in the maxillary sinus for these defects is anteriorly in the 
region of the canine fossa. 

THE ALVEOLAR BOUNDARY. 

Much greater importance has been given to the aetiological 
relation of the alveolus to the maxillary sinus than it really de¬ 
serves, as recent years have shown that carious roots of teeth 
are responsible only for a small percentage of maxillary sinus 
empyemas, much smaller than was formerly supposed. Statistics 
now prove that not more than 25 per cent, of cases result from 
this cause, while in former years this source would seem to supply 
from 90 to 100 per cent, of all reported cases. However, that they 
do occur in a given number is undisputed, so that no course of 
treatment should be instituted in' a case of empyema of the max¬ 
illary sinus until all upper teeth in relation to the antrum of the 
corresponding side have been thoroughly examined. 

The relation of the roots of the teeth to the antrum has been 
carefully studied by Zuckerkandl, Cryer, 216 and Underwood, 219 
with the following results: The floor of the normal maxillary 
sinus extends from the first premolar to the third molar. (Fig. 
42.) As the floor of the sinus does not run parallel with the alve¬ 
olar process, but is strongly curved above, it naturally follows 
that the root& of one or two teeth must come in closer proximity 

219. Underwood: Maxillary Sinus in Relation to the Teeth. Jour, of Lary., p. 620, 
1908. 






110 


THE ACCESSORY SINUSES OF THE NOSE. 


to the floor than those situated at the extremities of the sinus. 
These two teeth, it will be observed in the illustration, are the 
second premolar and the first molar, therefore, those to which 
attention should be first directed, not only for diagnostic but also 
therapeutic purposes, in empyema of this sinus. 

The distances between the apical portions of the roots of the 
teeth and the floor of the sinus are inconstant in different indi¬ 
viduals, depending upon the amount of cancellated bone structure 



which intervenes. Certain specimens show the distance separating 
these structures to he several millimeters (Figs. 43, 44), while 
in others the roots project distinctly into the sinus. (Figs. 45, 
46.) In the latter instance the sinus mucosa alone separates the 
root from the cavity proper. 

The interior of the maxillary sinus is not always smooth, hut 
quite often presents partial septa, which are usually situated on 
the floor and in the superior internal angle. (Fig. 39.) 

The normal maxillary sinus would then extend from the first 
premolar to the end of the second molar (on the inside to about 













2nd molar 
1st molar 



Cuspid 

1st bicuspid 
2nd bicuspid 


Fig. 43. Thick cancellated bone intervening between the teeth and the antral floor. 


■ 



Fig. 44.—Thick cancellated bone 
between the apex of the tooth root and 
the sinus floor. (Lateral view.) 


Fig. 45. —Roots of teeth projecting into the max¬ 
illary sinus cavity. 








































MAXILLARY SINUS. 


Ill 


the posterior osseous tip of the inferior turbinate); in front, from 
the inferior edge of the orbital ring to a point slightly below the 
roof of the mouth (floor of the nose),* and 
from a perpendicular line drawn from 
the canine tooth to the insertion of the 
last molar with the superior maxilla. (Fig 
42.) 

The Relation of the Structures Form¬ 
ing the Lateral Wall of the Nose to the 
Base of the Sinus from Without Inward : 
The nasal wall of the sinus shows a marked 
tendency to bulge outward, thereby forming 
an acute angle at its junction with the orbital 
wall. The insertion of the inferior turbinate 
is considerably higher up than one would sus¬ 
pect, almost dividing the partition into equal 
portions. (Fig. 47.) Below the turbinal insertion the structure 
is entirely osseous, while, above, the pars membranacea, divided by 



Fig. 46. —Lateral view of 
tooth root projecting into the 
maxillary sinus. 



Fig. 47.—View of maxillary sinus 
from without, showing place of exit of 
point of needle when introduced intra- 
nasally beneath the inferior turbinate at 
the usual position for exploratory needle 
puncture. 



Fig. 48. —Ostium divided by ridge of 
mucous membrane. 


the uncinate process, occupies much of the superior portion. 
(Figs. 38, 47.) 


* Hajek teaches the floor of a normal antrum should equal the line of the nasal floor. 
This is only true in children before the second dentition, as after this time it becomes deeper 
through reabsorption of bone. 






112 


THE ACCESSORY SINUSES OF THE NOSE. 


NORMAL POSITION OF OSTIUM. 

The ostium of the maxillary sinus lies in the anterosuperior 
portion of the sinus, at the junction of the superior and internal 
walls. Its position is almost constant within a certain limitation, 
rarely being situated behind the median line. (Figs. 38, 42, 47.) 
It may assume one of several forms: round, oval, kidney shaped, 
or in the nature of a long slit; the oval form, however, predomi¬ 
nates. The size varies from 2 mm. to 1.7 cm. by 1.1 cm., the aver¬ 
age ranging from the size of a buckshot to that of a pea. 220 This 
opening is not situated as a window in a wall communicating di¬ 
rectly from within outward, hut takes a distinct direction up¬ 
ward, backward, and inward. From the nasal aspect the direction 
is naturally downward, forward, and outward. Occasionally, from 
the antral side, one notes that two ostiums situated side by side are 
present in the space normally occupied by one. This is only appar¬ 
ent and is caused by a reduplication of mucous membrane or a 
ridge of bone dividing the normal ostium, thereby giving it a 
bilateral appearance. (Fig. 48.) 


ACCESSORY OSTIUMS. 

When an accessory ostium is present (about 10 per cent, of 
cases), it is situated posteriorly and often inferiorly to the normal 
opening in some portion of the pars membranacea. It lies either 
above or below the uncinate process, between its bony prolonga¬ 
tions, and is usually round, often being considerably larger than 
the normal ostium. (Fig. 49.) Unlike the latter, it assumes no 
direction, but communicates directly with the nasal cavity in the 
middle nasal passages. They do not necessarily occur singly, but 
may number two, three, or even four. (Fig. 50.) 

Accessory ostia are seldom seen in children, 220 221 222 being a product of 
later life, therefore, are undoubtedly connected with the bony reabsorption.* * 


Abnormalities and Anomalies of the Maxillary Sinus. 

These may consist of several varieties: 1. Overdeveloped or 
enlarged sinus. 2. Abnormally small sinus. 3. Peculiarly-shaped 


220. Oppikofer: Beitrage zur Normalen und pathologischen Anatomie der Nase und 
direr Nebenhohlen Arch. f. Lary., Bd. 19, S. 32, 1907. 221. Giraldes: Ueber die 

bcMeim-Cysten der Oberkieferhohle. Virchow’s Arch., Bd. 9, S. 463,1856. 222. Schaeffer, 
lhe Sinus Maxillans in Man. Ann. Otol., Rhin. and Lary., p. 815, 1910. 

* Oppikofer (220) found accessory ostiums in two instances in children, 7 and 11 vears, 
respectively. 




Accessory ostium 

Processus uncinatus 
Pars membranacea 



Normal ostium 


Accessory ostium 


Maxillary sinus 


Fig. 50 .—Several accessory ostiums. 









Orbital ethmoid 
cell 



Anterior eth¬ 
moid cells 

Projection of 
maxillary sinus 
under ethmoid 
capsule 
Middle tur¬ 
binate 


Maxillary sinus 


Fig. 52. —Excessive development of sinus due to over-reabsorption of cancellous tissue. 


Abnormally 

small 

maxillary 

sinus 



Uncinate 

process 

Posterior 

palatine 

fossa 


Inferior 

palatine 

fossa 


Fig. 53. —Marked asymmetry of maxillary sinuses. Excessive enlargement on the left due to outward 
expansion of anterior and lateral walls. Right sinus underdeveloped. 




























MAXILLARY SINUS. 113 

sinus. 4. Misplaced sinus. 5. Combination of two or more of 
these conditions. 

The principal cause of these conditions is hyper-reabsorption 
of the bone during the formation of the cavities. The opposite 
condition frequently prevails in number two, although the posi¬ 
tion of the walls also plays an important role in the causation of 
this form of anomaly. 

Misplaced sinus may be due to: (1) Irregularity in the con¬ 
formation of the facial bones, (2) malposition of one or more of the 
sinus walls, and (3) insufficient or partial reabsorption of the bone. 



Fig. 51. —Excessive overdevelopment of maxillary sinus on left with formation of orbital fossa. Roots of 
teeth projecting into floor of antrum. 


1. An overdeveloped sinus may be enlarged in several direc¬ 
tions, due to the above-mentioned liyper-reabsorption of the bone, 
including all portions of the sinus. (Figs. 51, 52.) 

a. Reabsorption toward the orbit. (Fig. 51.) 

b. Reabsorption into the palate bone. (Fig. 53.) 

c. Reabsorption into the hard palate. (Fig. 54.) 

d. Reabsorption into the malar bone. 

These are of little practical importance, with the exception of 
that into the hard palate, in which case Hajek says a bulging of 










114 


THE ACCESSORY SINUSES OF THE NOSE. 


the hard palate may take place when empyema with pressure 
occurs. The anomaly consisting of reabsorption toward the orbit 



Fig. 54.—Reabsorption of bone into the hard palate, bringing the maxillary sinuses into direct relation 
with the roof of the mouth. 


is of theoretical importance when one considers the possibilities 
of ophthalmic complications, as well as of transmitting inflamma¬ 
tion through the infra-orbital nerve. 



Anomalous Position of Walls. 

1. A rather uncommon source of enlargement of this sinus is 
the bulging outward of the anterior and lateral walls, as shown in 
Fig. 53. This protrusion of the walls is more apparent than real 
when one takes into consideration the asymmetrical formation of 





MAXILLARY SINUS. 


115 


these specimens. It will also be noted that reabsorption has 
occurred more markedly in all of the enlarged sides than in the 
other walls. 

2. The occurrence of an abnormally small sinus may be due to 
the two causes mentioned above, i.e., insufficient reabsorption and 
malposition of the sinus walls. 

When the reabsorption has ceased before the sinus has become 
fully developed, we merely have a small sinus with greatly thick- 


Orbit 


Maxillary sinua 


1st molar 

Fig. 56.—Narrowing of the antrum due to sinking in of the anterior wall. 

ened walls. (Fig. 55.) The sinus occupies relatively the normal 
position. When the walls do not occupy the normal positions, 
not only the position but the shape and size of the cavity will be 
greatly changed. 

In the course of examination of perhaps a thousand or more specimens the 
author has never seen one case of extensive protrusion outward of the anterior max¬ 
illary sinus wall which could not be clearly attributed to some pathological process. 
In the anatomical museum at Vienna (ZuckerkandPs collection) there are a number 
of specimens showing this peculiarity, all of them due to bone cysts of dentig¬ 
erous origin. In the opinion of the author dilatation of this sinus outward due to 
pressure from an empyema can not occur. (See Anatomy of the Lateral Wall of 
the Nose.) 






116 


THE ACCESSORY SINUSES OF THE NOSE. 


This deformity can take place in several ways: 

1. Sinking in of the canine fossa. 

2. Bulging outward of the lateral nasal wall. 

3. Combination of these two. 



1. Sinking in of the canine fossa: This naturally narrows the 
antero-posterior diameter of the cavity, and its recognition is of 
surgical importance, as the operation through the alveolus of the 



second premolar and first molar would miscarry, the drill pene¬ 
trating into the canine fossa in front of the antrum. (Fig. 56.) 

2. Bulging outward of the inferior portion of the lateral nasal 
wall occurs at the expense of the superior portion of the sinus, 




MAXILLARY SINUS. 


117 


narrowing the antrum from above downward and placing the pars 
membranacea in intimate connection with the orbit. This anomaly 
would make the needle puncture for diagnostic purposes through 
the middle nasal passage a most dangerous undertaking and abso¬ 
lutely preclude the possibility of operating through it. (Fig. 57.) 
When the sinus is contracted below the insertion of the in¬ 
ferior turbinate by bulging outward of the lateral wall, an at¬ 
tempted operation through the alveolus would result in the 
point of the instrument appearing through the floor of the nose. 
(Fig. 58.) 

Peculiarities in the contour of the sinus, as well as misplaced 
sinuses, depend upon a combination of the above conditions. 


FORMATION OF PARTITIONS IN THE MAXILLARY SINUS. 223 ' 224 

The formation of complete partitions is, fortunately, of rare 
occurrence, although partial partitions and ridges are commonly 
met with. Perhaps the most 
common form of complete par¬ 
titions is the perpendicular di¬ 
viding the antrum into an an¬ 
terior and posterior division. 

(Fig. 59.) In this case the two 
ostiums are to be found, one sit¬ 
uated in the hiatus in the nor¬ 
mal position, and the other, for 
the posterior portion, in the su¬ 
perior nasal passage, immedi¬ 
ately above the middle turbinate. 

(Fig. 60.) 

The morphology of this ano¬ 
maly can be readily grasped 
when one considers the poste¬ 
rior division as a misplaced eth 
moid cell. That this is really the 
case is proved by the number oc¬ 
curring in which the size of the posterior compartment varies from 
a small space to half the antral cavity. (Fig. 61.) The constant 

223. Zuckerkandl (45), S. 284. 224. Underwood: An Inquiry into the Anatomy and 
Pathology of the Maxillary Sinus. Journ. of Anat. and Physiol., Bd. 44, p. 354, 1910. 



Fia. 59.—Complete septum dividing antrum into 
an anterior and posterior compartment. 



118 


THE ACCESSORY SINUSES OF THE NOSE. 


position of the ostium in the superior nasal passage is another 
point in favor of this theory. 

One can readily appreciate how confusing this would be if the posterior portion 
was affected with all the symptoms of an ordinary maxillary sinusitus and a needle- 
puncture made in the usual place under the inferior turbinate which would only 
enter the anterior unaffected part with negative result. 225 

The mucous lining of the maxillary sinus consists of three 
layers: ciliated epithelial, tunica propria, and periosteal; the two 
latter, however, are so intimately connected that to all intents and 



Fig. 60. —Ostiums of a double maxillary sinus, a, stylus into anterior compartment; b, stylus into 

posterior compartment. 


purposes they form one. The glandular supply is very 
meagre, being confined, for the most part, to the region of the 
ostium. 226 The entire thickness of the combined layers is rarely 
more than .02 millimeter. It is especially loose around the 
ostium, and prone to cedematous swelling on slight irritation. 
It is curious to note with what facility this thin, delicate 
layer assumes a thick, myxomatous mass of tissue under 
the influence of suppurative processes of comparatively recent 
origin. 


225. Boulay (Sinusitis Maxillaires, Diverticulaires et cloisonnees, Arch, internat. de 
laryng., vol. 11, p. 375, 1898) has reported such a case. 226. Tunis: Inflammation of the 
Sinus Maxillaris, with Special Reference to Empyema, etc. Laryngoscope, p. 939, 1910. 





MAXILLARY SINUS. 119 

Relation cf the Maxillary Sinus to the Lachrymo-nasal 
Canal . 2264 

Although the lachrymal fossa lies well above the maxillary 
sinus, it must be remembered that the antrum is in intimate re¬ 
lationship with the bony duct lower down, and, indeed, a portion of 
the internal sinus wall forms the entire lateral wall of the osseous 
duct. (Fig. 61a.) The internal aspect of the sinus shows a de¬ 
cided bulging at this point (lachrymal eminence), which may be so 
marked as to cause a distinct narrowing of the antero-superior 
angle of the sinus. (Fig. 61a.) When reabsorption of the bone has 
made a deep prelachrymal recess in the antero-superior portion of 
the sinus cavity, the lachrymal eminence may project to such an 
extent as to considerably narrow the sinus lumen. This is of no 
little import from a pathological point of view, for if this narrow 
recess was not thoroughly curetted during the radical operation, a 
relapse is almost certain to occur. 

During the Caldwell-Luc and Denker operations this structure 
should he avoided, although in the event of its being wounded less 
harm results than one would naturally expect. 

Blood Supply .—The mucosa receives its blood supply from a 
branch of the nasal artery which penetrates the ostium, as well as 
through the pars membranaeea. The antral walls receive a double 
supply, as both sides are covered with periosteum, through which 
they receive double nutrition. This possibly explains why severe 
ulceration of the mucosa is often unaccompanied by any manifes¬ 
tations of disease in the underlying bone. 


Surgical Anatomy of the Lateral Wall of Nose in Reference 
to the Maxillary Sinus. 

Three separate portions of the lateral nasal wall are of in¬ 
terest in this respect: 1. Posterior third of hiatus semilunaris 
(infundibulum). 2. Pars membranaeea. 3. That portion directly 
beneath the centre of the inferior turbinate (maxillary process of 
inferior turbinate). The maxillary ostium, as has been stated in 
the chapter on the anatomy of the lateral wall of the nose, is sit¬ 
uated in the posterior third of the hiatus semilunaris. (Fig. 26.) 

226a. Fein- Ueber Beziehungen zwischen Kieferhohle und Tranennasengang. Archiv. 
f.Laryng., Bd. 26, S. 29, 1912. 




120 


THE ACCESSORY SINUSES OF THE NOSE. 


SOUNDING THE MAXILLARY OSTIUM. 227 

Contrary to the opinions of some rliinologists, the author is in¬ 
clined to believe that the normal ostium of the maxillary sinus, 
even after removal of the anterior portion of the middle turbinate, 
can only be sounded and catheterized in a very small percentage of 
cases. 228 The natural barriers to sounding are: 1. The processus 
uncinatus. 2. The bulla ethmoidalis. 3. The depth of the hiatus 
and infundibulum. 4. The position of the ostium in the infundib¬ 
ulum. 

1. The processus uncinatus does not protrude from the lateral 
wall of the nose like an ordinary shelf, but rather like the lower 
edge of an oblique pocket. On account of this, the deepest part 



Fia. 62.—Unusually large bulla ethmoidalis. Fig. 63.— Upward displacement of bulla with 

enlargement of the hiatus semilunaris. 


(infundibulum) is not directly outward, but rather downward and 
forward, and it is at the very lowest depth of the infundibulum 
that the ostium is situated. The depth of the hiatus with infun¬ 
dibulum varies between 3 mm. and 9 mm., the mean depth being 
6 mm. 

2. The ethmoidal bulla, while always constant, is one of the 
most variable structures in the lateral wall of the nose. It may 
be so large as to protrude beyond the inferior border of the middle 
turbinate, following the middle nasal passage (Fig. 62), or be so 
small as to form merely the straight floor of the ethmoidal cap¬ 
sule. (Fig. 63.) 

On the position of the bulla depends largely the possibility of 
introducing the tip of the sound into the maxillary ostium. If 
slightly enlarged, it adds to the natural difficulties by not only 

227 . Siebenmann: Verhand. deutscher Naturforschr. Halle, 1891. 228. Cryer 

(Trans Section on Lary. A. M. A., p. 160, 1902) says it is impossible to sound the antrum 
through the nose. 
















Fig. 61. —Maxillary ethmoid cell at posterior superior angle of antrum. 


Lachrymal fossa 


Prelachrymal recess 
Lachrymal canal 



Ostium of sinu3 


Fig. 6la.—Relation of the lachrymal duct to the maxillary sinus. 



























MAXILLARY SINUS. 


121 


deepening the infundibulum, but also narrowing the slit-like hiatus 
semilunaris. (Fig. 20.) 

3. The depth of the hiatus and infundibulum depends upon the 
width of the processus uncinatus and the development of the bulla. 

4. The position of the ostium in the infundibulum presents the 
last natural difficulty to sound this sinus. It is not, as one would 
suppose, set in the lateral wall of the nose, flat as a window in the 
wall of a house, but in such a manner that its direction from within 
out is forwards, downwards, and outwards, which very materially 
adds to the difficulty of sounding, as the tip of the instrument must 
be bent in a corresponding position. It would, therefore, appear 
that the difficulty in sounding the maxillary sinus does not depend 
so much upon the size of the ostium as upon its almost inaccessible 
position in the depths of the infundibulum. 

In a certain small number of cases these anatomical structures 
may he so formed as to permit a probe bent backward on itself at 
an angle of 60 degrees to be introduced through the natural ostium 
into the sinus. The entire manipulation, however, is so uncertain 
and unsatisfactory, at least in my hands, and the needle puncture 
below the inferior turbinate so swift and sure, that we have long 
since abandoned attempts at sounding as a diagnostic procedure. 
The success reported by certain rhinologists in catheterizing this 
sinus through the natural ostium is probably due to the fact that 
the end of the catheter either found an accessory ostium or, what 
is more probable, forced its way through the thin and yielding pars 
membranacea. In either case it would be practically impossible 
to judge whether the lavage had occurred through these structures 
or the natural ostium. 

^Etiology. 

The antrum is more often diseased than its fellow sinuses, 
because it has one more aetiological factor, i.e., the intimate re¬ 
lation of its floor to the roots of the teeth. It will be remembered 
that the sinuses are usually affected through their ostia, occasion¬ 
ally through the circulatory system. The maxillary sinus not 
only presents this to a marked degree on account of the extremely 
unfavorable situation of the ostium, but, in addition, certain affec¬ 
tions of the alveolus are prone to, in turn, affect this cavity. 

The relation of the teeth to the floor of the sinus has already 
been discussed (see Anatomy); however, it is well to repeat that 
the teeth from the canine to the wisdom bear more or less relation 





122 


THE ACCESSORY SINUSES OF THE NOSE. 


to the floor, the second premolar and the first molar being the 
closest in proximity; therefore, any inflammation around the roots 
of these could easily be transmitted to the sinus mucosa. We then 
have the following setiological factors: 

1. Idiopathic (arising in the sinus itself), rare. 

2. Direct extension from the nasal mucosa (coryza). 

3. Infectious diseases (circulatory system). 

4. From alveolus (contiguity—blood) (continuity—bone). 

5. Through contamination from overlying sinuses. 

6. Foreign bodies. 

7. Traumatism (galvano-cautery and tamponade), direct or in¬ 
direct. Frostbite. 228a 

8. Osteomyelitis, tuberculosis, syphilis, and malignant tumors. 

9. Chronic or latent empyema. 

1. Idiopathic. —Disease of the maxillary sinus arising from the 
direct invasion of bacteria, without other appreciable causes, al¬ 
though reported by various authors, we have never observed. 

2. Direct Extension from the Nasal Mucosa. —This is the 
most frequent cause of maxillary sinusitis. Whenever general in¬ 
flammation of the Schneiderian membrane occurs the mucosa of 
the sinuses is affected. In all cases of acute coryza there is bound 
to be more or less inflammation of the maxillary sinus. When 
general resolution sets in, the sinus membrane also regenerates, 
and it is only in those cases where the drainage is seriously inter¬ 
fered with that the disease becomes chronic. We can readily see 
how easily this can occur, especially in the maxillary sinus, where 
the ostium is situated so high, and the middle turbinate, when 
swollen, may occlude it. It is not the presence of the secretion so 
much as the pathological changes in the mucosa occasioned by the 
pressure and insufficient aeration that causes the disease to be¬ 
come chronic. This will explain the fact that acute maxillary 
sinusitis is so often observed after the primary nasal affection has 
disappeared. In repeated attacks of coryza the sinus mucosa 
which has been the seat of previous attacks will always show an 
especial predilection for renewed inflammation; in this way the 
disease may also become chronic. 

3. Infectious Disease. —The most important of this group is 
influenza, but the precise reason why this disease shows such a 

228a. Major, of Montreal, has on two occasions succeeded in tracing empyema of the 
antrum as the direct sequence of frostbite of the cheek. N. Y. Med. Journ. p. 197 Aug. 
19, 1893. ’ 



MAXILLARY SINUS. 


123 


marked predisposition to affect the sinuses, a swell as the mode of 
infection, must for the present remain unanswered. 

In Germany and Austria Hungary, influenza plays the great role in the 
causation of sinus diseases. In America it is different. The explanation of this 
lies in the fact that Russia, being the original starting point for this disease, the 
epidemics are not only much more severe in that portion of the world, but return 
every winter with great regularity. Another cause which is not to be under¬ 
estimated is the negligence of the poorer folk, especially the peasants, in seeking 
immediate treatment as soon as the disease is acquired. On this account such 
pathological changes have often occurred when medical attention is first sought, 
that serious and often subsequently fatal complications have intervened. In the 
cities of the United States where dispensaries are to be found on almost every 
fourth corner, these conditions are practically unknown. These are the main 
reasons why sinus disease, particularly the severer cases, is more prevalent in 
Europe than with us. 

4. From the Alveolus.— It was formerly thought that every 
case of antral empyema was directly due to dental infection. This 
opinion has gradually changed, until now the relation is placed at 
approximately 20 per cent. 

Certain authorities cling more or less tenaciously to the dental origin, thus 
Tilley 229 would seem to place it at 100 per cent., Lermoyez 230 more than 50 per 
cent., Dutrow 231a at 65—70 per cent., Dunning 23lb 50 per cent., Carmody 231c 
33 per cent. Barnhill 2310 25—40 per cent., Andrews 2310 10 per cent., Luc 231 at 50 per 
cent. Among those who hold the opposite opinion may be mentioned Cryer 216 
(29 per cent.), L. Turner 233 (30 per cent.), Richards 234 ( 25 to 30 per cent.), 
Piffl 235 ( 26 per cent.), and Hajek 236 (8 per cent.). 

As far as we have been able to ascertain by a careful review of our own 
cases we would place the proportion at from 20 to 30 per cent. It is impossible 
to fix on a definite figure, as in certain instances where the teeth were affected, it 
was evident that the dental disturbances were secondary to the sinus affection. 
This was proven by the skiagrapic pictures which clearly showed the ostitis 
extending downward from the floor of the diseased antrum toward the apices 
of the roots of the healthy teeth (first and second molars). 

The supposition previously existed that a carious tooth caused 
the infection simply by direct extension into the sinus by 

229. Tilley: Suppuration of the Maxillary Antrum, with Special Reference to Diagnosis 
and Treatment. Laryngoscope, p. 97, 1904. 230. Lermoyez: A discussion on the Ultimate 

Results of Surgical Operation, etc. Journ. of Lary., p. 576, 1902. 231. Luc: Lemons sur le 

suppuration, etc., p. 274, 1910. 231a. Dutrow: The Diagnosis and Treatment of Maxillary 

Sinusitis. Trans. Am. Acad, of Ophthalmology and Oto-Laryng, p. 286, 1920. Laryngoscope, 
p 296, May, 1921. 231b. Dunning: Surgical Treatment of Chronic Maxillary Sinusitis of 

Oral Origin. Journ. Am. Med. Assn., p. 1391, Nov. 20,1920. 231c. Discussion to Dutrow. 

231a. 232. Cryer: Anatomy of the Face, p. 64, 1901. 233. L. Turner and Lewis: A Fur¬ 

ther Study of the Bacteriology of Suppuration in the Accessory Sinuses of the Nose. Edin¬ 
burgh Med. Journ.. Apr., p. 293,1910. 234. Richards: Origin of Antral Ernpyemate. Ann. 

Otol., Rhin. and Lary., p. 76, 1905. 235. Piffl: Zur Operation u. Casuistik der Chron. 

Oberkieferhohleneiterungen. Pragermed. Wochen., No. 17,18,1906. 236. Hajek: Em Bei- 

trag zur Kenntniss des dentalen Empyems der Kieferhohlen, etc. Wiener klin. Woch., No. 
16, 1908. 




124 


THE ACCESSORY SINUSES OF THE NOSE. 


continuity, being practically always limited to the second bicuspid 
or first two molars. We have now discovered that this is 
but one of several ways whereby antral infection results from 
dental origin. 

a. By direct continuity (carious tooth). 

b. Through periostitis. 

c. Through the circulatory system. 

d. Circumscribed or diffuse ostitis of the alveolar process. 

e. Rupture of an infected dentigerous cyst. 

/. Secondary to extraction of teeth. This infection may occur 
in three ways. 236a 

(1) Where roots of teeth lie bare within the antrum and on 
extraction leave a fistula which leads directly into the mouth thus 
permitting infection to occur by direct passage of pathogenic 
micro-organisms. This I believe to be exceedingly rare as I do 
not recall even having seen an anatomical preparation in which 
the roots were not at least covered over by the lining membrane 
of the sinus. 

(2) Where the dental roots penetrate the osseus floor of the 
sinus but are covered by the sinus mucosa. After extraction, 
through injudicious probing or infection, suppuration occurs 
which melts away the soft tissues with a general infection of the 
sinus cavity. This I think is more theoretical than actual for 
general experience shows that when a point of focal infection is 
removed in sinus work the remaining portion of the sinus fre¬ 
quently returns to normal and if not already diseased, practically 
never becomes so after the operation. The tolerance of the healthy 
antrum to purulent secretion from over-lying sinuses without 
itself becoming infected is too well known for detailed description. 

(3) Directly as a result of traumatism from the improper 
extraction of teeth. This may occur from the twisting and turn¬ 
ing in the endeavor to loosen the roots whereby the apices of the 
roots are forced through the antral floor. The same condition may 
occur where the root has been broken off and in the attempt to 
grasp it, the fragment is pushed through the floor into the 
sinus cavity. 

236a. Lyons: Empyema of the Antrum of Highmore secondary to Extraction of Teeth 
Journ. Am. Med. Assn., p. 487, Feb., 1922. 




MAXILLARY SINUS. 


125 


a. By direct continuity. Three forms are observed: 1. Mani¬ 
fest caries. 2. Hidden caries. 3. Dead teeth. 

a. Direct Continuity. —(1) Manifest caries: After the caries 
has attacked the enamel, dentin, and pulp successively, the higher 
toward the root of the tooth it reaches, just that much more diffi¬ 
cult is the drainage. The dental canal finally becomes obstructed, 
the carious process breaks through the apex of the root, with the 
formation of an abscess. The constantly-accumulating pus seeks 
an outward passage, which occurs either into the gum or into the 
maxillary sinus, with the formation of an acute antral empyema. 

(2) Hidden caries: Infection from this source usually occurs 
beneath a filling or crown. The process may be so insidious as 
to entirely escape the notice of the patient; however, on close 
questioning, the history of trouble with that tooth is usually 
elicited. The pathological process is precisely the same as that 
with manifest caries. 

(3) Dead teeth: Teeth in which the nerve has been killed ex¬ 
hibit little reaction against bacterial invasion, consequently infec¬ 
tion easily gains entrance to the root without any subjective 
symptoms. The pulp becomes easily infected through the dentin, 
as the latter does not react as a sound tooth. When a rupture of 
an acute abscess of a tooth root into the maxillary sinus occurs 
the symptoms are so marked as to be almost unmistakable. The 
gum and alveolar process directly above the offending tooth are red, 
swollen, and shiny in appearance, and extremely tender on deep 
palpation. Aching in the affected tooth, as well as a feeling that 
the tooth is longer than its fellows, is marked. On percussion it is 
exquisitely sensitive. These symptoms of pain and tenderness 
may suddenly subside on rupture of the abscess into the antrum. 
Symptoms of a foetid purulent discharge from the maxillary sinus 
now for the first time present themselves. On examination of the 
tooth it is possible to introduce a fine sound through the socket 
directly into the antrum. This, however, does not always hold 
true, as there may be present 1 mm. or more of cancellous bone 
through which the inflammatory process has passed without its 
being broken and liquefied. 

b. Through Periostitis .—Periostitis of the alveolar process is 




126 


THE ACCESSORY SINUSES OF THE NOSE. 


usually dependent upon an earlier periosteal abscess, yet may re¬ 
sult from constant irritation by grinding, especially when a neigh¬ 
boring tooth has been extracted. The careless extraction of a 
tooth seems also to be the predisposing moment in many of these 
cases, although the simple opening of the antrum by drawing a 
tooth is not in itself sufficient grounds to cause an infection.* If 
several millimetres of spongy bone lie between the root apex and 
the antral cavity, the periostitis may cause a circumscribed ostitis 
of this cancellated bony partition. Under these circumstances, 
after extracting the tooth, the drill will easily penetrate the inter¬ 
vening osseous structure which has become softened by the disease 
and penetrate the antrum. It must, however, be mentioned that 
the thicker the layer of bone between the teeth and the floor of the 
antrum, the less the liability of the individual to contract maxillary 
sinusitis from dental caries. Hajek 236b mentions a curious route 
of infection from periostitis. The second left incisor was carious, 
from which sprang a periostitis. The infection gradually spread 
upward through the pyriform aperture to the floor of the nose and 
infected the antrum, spreading by contiguity through the inferior 
nasal passage. 

c. Through the Circulation™ —The intimate anastomosis of 
the antral and dental veins explains how readily infection can ex¬ 
tend from one to another. While this hypothesis has not definitely 
been proved, nevertheless, in those cases where a tooth has been ex¬ 
tracted preparatory to the Cowper operation, and a considerable 
layer of apparently normal bone must be pierced before the sinus 
is reached, we can assure ourselves that the circulatory system has 
acted in a large measure as a medium of transmission for the in¬ 
fecting micro-organisms. Microscopical examination of these cases 
would show a healthy area of bone between the focus of infection at 
the root of the tooth and the secondary area on the nasal mucosa of 
the sinus. 

d. Circumscribed or Diffuse Ostitis of the Alveolar Process.— 
This is especially easy to diagnose, for here we have a purulent in¬ 
flammation of the alveolus. With circumscribed ostitis frequently 
a portion of bone is necrosed ; the empyema does not heal until 
this sequestrum has either been removed or sloughed off. The 


Hajek (p* 71, note) lays particular stress upon this fact, and cites four cases in which 
direct coramunication between the mouth and antrrm had been established after extraction 
of teeth, yet no sign of inflammation in the sinus was, or ever had been, present. 
j xr^’ v?ui e k: Lehrbuch, 1915, S.71. 237. Striibel: Ueber die Beziehungen der Gefasse 
der .Kie.erhohle zu denen der Zahne. Monatschr. f. Ohrenheilkunde, No. 6, S. 249, 1904. 



MAXILLARY SINUS. 


127 


pathognomonic symptom of these cases is the exquisitely foetid odor 
to the purulent secretion, which is always of extreme disgust to the 
patient. In these cases, even after extraction of the tooth in the 
diseased area, there is usually no direct communication with the 
sinus, in contradistinction to the root abscess. The abscess also 
exhibits a tendency to rupture outward, thus forming a fistula from 
the maxillary sinus through the alveolus into the mouth. The exact 
course the infection follows in these cases has never been satisfac¬ 
torily proved. Tilley 237a believes it occurs through the lymph- 
channels, while Killian 237b and Zarnico 237(5 contend that it travels 
along the spaces for the vessels and nerves. Hajek 237d advances 
the theory that it makes its way through the canaliculi in the bone 
in precisely the same manner as has been observed in the posterior 
wall of the frontal sinus and in the superior wall of the sphenoid. 

e. Rupture of an Infected Dentigerous Cyst into the Antrum .— 
This possibility has been mentioned, but, on account of its extreme 
rarity, deserves no further consideration. 

Finally, it must not be forgotten that dental trouble may be 
secondary to the sinus disease. A glance at Figs. 45 and 51 will 
show us that roots of previously healthy teeth may become dis¬ 
eased through inflammation due to their close proximity to infec¬ 
tious material. That this does occur will be illustrated in the 
following case: 

H. K., 40 years. Acute maxillary sinusitis. No history of dental trouble on 
that side. Sinusitis cured by intranasal puncture and frequent lavages. Several 
weeks afterwards noted pain in second bicuspid on diseased side, sensitive to per¬ 
cussion. On lavage no pus or secretion in the antrum. Tooth extracted, root in¬ 
flamed with beginning abscess formation. Body of tooth perfectly sound. Patient 
experienced no further trouble either from site of jaw or of sinus. 

5. Through Contamination from Overlying Sinuses.— This 
can occur only from the frontal and possibly anterior ethmoidal 
under certain anatomical and pathological conditions. The ana¬ 
tomical conditions are that the uncinate process must be of sufficient 
width to carry and guide the purulent secretion to its posterior ex¬ 
tremity, and the maxillary ostiums the sinus. The pathological 
conditions are that the sinus mucosa must be in a condition to be¬ 
come infected from the secretion. 


237a. Tilley: Some Observations upon Suppurations of the Maxillary Antrum. Trans, 
of the Odontological Society of Great Britain, 1903. 237b. Killian: Miinch. med. Woch., 
Nos. 32 and 33, 1892. 237c. Zarnico: Lehrbuch, S. 608, 1910. 237d. Hajek: Lehrbuch, II 
Auflage, S. 66. 






128 


THE ACCESSORY SINUSES OF THE NOSE. 


The mucosa of the sinuses exhibits great tolerance toward purulent secretion 
before becoming infected, as the following case will illustrate: A. A., 40 years, 
frontal sinus trouble for several years. No maxillary trouble. After several weeks’ 
treatment the secretion became thin and watery but did not entirely cease. Before 
discharging her, an exploratory needle puncture of maxillary sinus was made, which 
brought out a considerable quantity of thick purulent material. In forty-eight hours 
another puncture was made and the injected fluid returned perfectly clear. This 
was substantiated a few days later, showing that the antrum had merely acted in the 
capacity of a reservoir and was not itself affected.* 


6. Foreign Bodies. 238-230 —Sinus suppuration can be occasioned 
by the action of foreign bodies which have found their way into the 
antrum. The mode of ingress may occur in three ways: 

(1) Through the natural ostium or an accessory ostium with¬ 
out injury to the sinus walls or mucosa. In this manner many 
varied substances may find lodgement in the antrum, as blood, 
vomited matter, snuff, parasites, and even worms. Chloride of 
iron, which has been used to control epistaxis, has been known to 
enter the maxillary sinus and set up a purulent discharge. 

(2) Through the osseous walls, with injury to the mucosa. This 
may occur either through the nasal or the anterior maxillary wall. 

(3) Through an artificial opening in the alveolus. When a 
foreign body enters either the antrum without external force 
(through the ostium) it must either be infected or irritating to the 
lining mucosa in order to cause an immediate empyema. In the 
course of time the irritation produced will ultimately lead on to 
infection, although it will depend largely upon the nature of the 
penetrating substance as to the exact pathological condition evoked. 
We must always bear in mind the tolerance of the lining mucosa to 
extrinsic bodies without itself becoming greatly affected, as we see 
in those cases in which the maxillary sinus acts as a reservoir for 
the sinuses lying superiorly. 

Supernumerary and inverted teeth, 239a by their growth upward 
into the floor of the antrum, may produce sufficient irritation to 
lower the vitality of the mucosa and become the focus of a spreading 
infection which subsequently involves the entire cavity of the sinus' 

7. Traumatism—Direct and Indirect. —Under this heading we 
understand an empyema set up directly as the result of an injury 
either to the external or nasal walls. Through the external walls: 


Foreign bodies of an aseptic nature have been known to lie dormant in the antrum 
for y £ a Q rs J^V- 1 an ^ cute Infection caused their presence to become manifest. 

1008 iqoo 11 M 6mdk T e V n der gieferhohle. Heymann’s Handbuch Die Nase, S. 
00 L 19 !1 23 ^o N T COmb: L° re ; gn Bod ^ es 1T Y the Antrum. Trans. Am. Lary. Assn., 

P 911 k 239a \9?° T & Mackenzie: Two Cases of Maxillary Sinus Involvement 
Homeo. Eye, Ear and Throat Jour., Jan., 1910. 





MAXILLARY SINUS. 


129 


This is usually the result of an accident from a fall, blows of a blunt 
instrument, unskilled extraction of teeth, etc. 

Ends of tooth roots which have been broken off and forced into the sinus through 
attempts at extraction have causal a purulent discharge in this cavity. Cham¬ 
berlin 240 recently communicated an interesting case in which the dentist, in ex¬ 
tracting a wisdom tooth, unintentionally broke off one of the roots, which, during 
attempts at further extraction, was forced into the antrum, setting up a purulent in¬ 
flammation. During irrigation through a needle puncture the broken root was 
washed out into the nasal cavity and removed, the patient promptly recovering. 

The empyema is occasioned by the wounding of the mucous 
membrane, which subsequently becomes infected either from the 
putrefaction of the free blood which has accumulated in the cavity, 
or from the lack of resistance of the mucosa, due to the injury caus¬ 
ing a favorable soil for the growing of the micro-organisms of 
suppuration. 

The antral mucosa possesses decided resisting powers toward secondary infec¬ 
tion after an injury. As a rule, healing by primary intention will take place under 
simple antiseptic dressings, even though the injury be extensive. 241 

Indirect .—Through the nasal wall: This probably occurs 
through wounding the pars membranacea, followed by subsequent 
infection. This may be caused by galvanocautery of the ethmoid 
region, 242 tamponing the nose, 243 and intranasal surgical pro¬ 
cedures. 244 

8. Osteomyelitis, Syphilis, Tuberculosis, and Malignant 
Tumors.— Osteomyelitis. — While this affection as an aetiological 
factor in purulent inflammation of the mucosa is not uncommon dur¬ 
ing the first years of infant life, after that time it is extremely 
rare, especially after puberty. Cases of sinusitis, however, have 
been reported 245 which were clearly the result of a pre-existing 
osteomyelitis. 

Syphilis .—Maxillary sinus empyema as a result of syphilitic in¬ 
fection can occur only through necrosis of some portion of the bony 
wall through the dissolution of a tertiary lesion. The nasal wall 
beneath the inferior turbinate and the anterior wall have been re¬ 
ported thus affected, 246 but the process is rare enough, as the ex¬ 
treme paucity of the reported cases will substantiate. 

240. W. C. Chamberlin. Personal communication, 1915. 241. Haga: Krieg chirur- 
gische Erf. aus dem Chin.-Jap. Kriege, ’94-97. Berlin, 1897. 242. Tilley (229), p. 102. 
243. Avellis: Einige kurze klin. Bermerk. z. Lehre vom Kieferhohlenempyem. Arch. f. 
Lary., Bd. 2, 1895. 244. Wertheim: Beitr. z. Path. u. klin. der Erkrank. d. Nasenneben- 
hohlen. Arch. f. Lary., Bd. 11, S. 80, 1901. 245. Menzel: Ueber primare akute Osteo¬ 
myelitis des Oberkiefers. Arch. f. Lary., Bd. 21, S. 100, 1909. 246. Neufeld: Tubercu- 

lose, Syphilis und Kieferhohleneiterungen. Arch. f. Lary., Bd. 17, S. 215, 1905. 

9 


✓ 





130 


THE ACCESSORY SINUSES OF THE NOSE. 


Tuberculosis .—Tubercular disease of the antrum occurs more 
frequently than with the neighboring sinuses, yet is of itself of 
great rarity. Koschier 247 reported two cases in which he believed 
the disease was quite primary, and shortly afterward Coakley 248 
published a similar case. A permanent cure followed the radical 
operation in both instances. The disease is usually dependent upon 
a focus of infection in some removed portion of the body which 
secondarily attacks the bone in the immediate vicinity of the sinus 
cavity. The seats of predilection for this process seem to be the 
alveolus of the superior maxillary and the lateral nasal wall. In 
true tubercular infection the bacillus will always be found on 
microscopical examination. 2476 

Malignant Tumors. —Sarcomas, and particularly rapidly-pro¬ 
liferating epitheliomas, on account of their poor blood supply, can 
break down and ulcerate, thus producing, by continuity, a purulent 
process within the sinus cavity. This form of empyema is char¬ 
acterized by the peculiar intensive odor of the discharge and its 
being mixed with blood and broken-down portions of the tumor. 
The lateral nasal wall is also usually displaced inward toward the 
nasal septum, thus greatly narrowing the nasal cavity on the af¬ 
fected side. The maxillary sinus is the seat of malignant disease 
more often than all the remaining sinuses together. 

9. Chronic or Latent Empyema.— Under certain circumstances 
maxillary sinus empyema may take its inception in a chronic form, 
particularly when the disease occurs from the alveolus. This is 
due to the primary irritation being mild and continued for some 
length of time, allowing the mucous membrane to react and fortify 
itself against the infection. The mucosa, however, finally suc¬ 
cumbs to the progressive inflammation, and a well-marked case of 
chronic empyema results. 

Sequelae and Unusual Conditions Found in the Maxillary Sinus. 

CYSTS . 249 

Two distinct varieties of cyst formation are found in the max¬ 
illary sinus: 1. Mucoid or retention cysts. 2. Dentigerous cysts. 

1. The mucoid cyst is characterized by single or multiple, semi- 
spherical, yellow or whitish protuberances on the floor or the nasal 

247. Koschier: Wiener Laryng. Gellsch. Monatf. Ohrenhk., S. 43, 1901. 247a. 

Cocks: Tuberculosis of the Maxillary Antrum with Tubercle Bacilli Present in the Wash¬ 
ings from the Antral Cavity. Laryngoscope, p. 766,1914. 248. Coakley: A Case of Tuber¬ 
culosis of the Antrum of Highmore. N. Y. Univ. Bulletin of Med. Sciences, p. 121, 1902. 
249. Alexander: Die Schleimhautcysten der Oberkieferhohle. Arch. f. Lary., Bd. 6, S. 
116, 1897. 



MAXILLARY SINUS. 


131 


wall of the antrum, ranging in size from a millet seed to that of a 
walnut. (Fig. 64.) Occasionally they may grow to such an extent 
as to completely fill the antral cavity. (Fig. 65.) As the name im¬ 
plies, they are occasioned by obstruction to the glandular outlets, 
due to some form of inflammation in the immediate neighborhood. 
This inflammation may be in a localized area of the mucosa, 250 as 
they do not necessarily depend upon any previous sinusitis. 

The primary contents of these cysts consist of a watery, albu¬ 
minous liquid containing leucocytes and degenerated epithelium, 



Fig. 64. —Cross section through both maxillary sinuses showing many small mucoid cysts. 
(After Giraldes.) 


which later becomes solid through a caseous degeneration. No 
symptoms are occasioned by the presence of these new growths 
in their original state, as most examples have been found at the 
autopsy which were never suspected during the life of the indi¬ 
vidual. 

2. Dentigerous Cysts (Cyst of Dental Origin ).—These are 
caused by disturbances in dentition. Two varieties may be dis¬ 
tinguished: 251 1. Those due to retention of unerupted teeth (im¬ 
proper development)—rare. These being due to some disturb¬ 
ance in the embryonal development, usually take their origin co- 
incidently with the eruption of the second teeth. They are char¬ 
acterized by having mature teeth growing from their internal 

250. Tunis (225), p. 931. 251. Heath: Injuries and Diseases of the Jaws, p. 367, 
1867, London. 









132 


THE ACCESSORY SINUSES OF THE NOSE. 


walls and ranging free into the cavity of the cyst. Oppikofer 2;jla 
has reported in detail one of these cases with illustration. (Fig. 66.) 


Orbit 


Maxillary sinus 


Inferior turbinate 



Anterior 
ethmoid cells 


Middle turbinate 


Mucoid cyst 


Maxillary sinus 


Fig. 65.—Large glandular mucoid cyst almost filling antrum of left side. 



2. Those due to inflammatory changes in the root membrane of an 
infected tooth (periodontal). 

The latter cyst is formed by a sac of tough connective tissue, 
which enlarges in an upward direction both into the spongy bone 


251a. Oppikofer: Zahnwurzelzysten. Arch f. Laryng , Bd. 25, H. 1, 1911. 
















MAXILLARY SINUS. 


133 


and into the maxillary sinus. (Fig. 66.) It does not cease grow¬ 
ing until an opening is found which allows the escape of the con¬ 
tinually-forming secretion either into the nose or into the mouth. 
The normal contents consist of a straw-colored, watery liquid, often 
containing cholesterin, but when infected becomes thick, brownish 
or chocolate-colored, sometimes degenerating into a cheesy mass. 
Hydrops antri is a name often falsely given 
to these cysts which contain thin, watery 
fluid. 

iETiOLOGY and Pathology. — Inflammatory 
changes in the root membrane. 262 After a tooth has 
become carious, micro-organisms find their way into 
the canal, causing a peridontitis at the extremity of 
the root. This inflammation results in the formation 
of a minute cyst on the tip of the root. (Fig. 67.) If 
the tooth is drawn at this stage, the cyst will fre¬ 
quently be simultaneously extracted. If, however, the 
irritation continues, and the canal becomes closed, re¬ 
tention of the inflammatory products will take place 
with subsequent dilatation and cyst formation. 

Symptoms.— In the earlier stages all 
symptoms may be lacking, as the growth 
takes place painlessly, and not until marked 
swelling occurs does the patient pay any 
particular note to the condition. During 
the later stages a hard, bony distention may 
he felt directly over the antrum in the region 
of the ala of the nose. In the alveolar 
region this swelling may yield slightly to pressure, emitting a 
parchment-like crackling, this being due to the partial absorption 
of bone from the ever-increasing pressure of the cyst. 

Occasionally the lateral nasal wall is pushed inward toward the 
septum, and even the roof of the mouth may show swelling over a 
considerable area. The cyst continues to enlarge until rupture 
either into the maxillary sinus, nose, or mouth occurs. If rupture 
takes place into the antrum, all the symptoms of a true maxillary 
sinusitis will supervene. 

Diagnosis. 253 — Dilatation of the anterior sinus wall, in itself, is 
enough to clear the diagnosis, as this condition is unknown in sinu¬ 
sitis. The parchment-like feeling, as well as inward distention, of 

252. Hoffman: Zur Path, der Kiefercysten. Zeitschr. f. Lary., Bd. 3, S. 467, 1911. 
253. Kudert: Ueber die Differential Diagnose zwischen Cysten und Antrum-Empyem. 
Arch. f. Lary., Bd. 16, S. 502, 1904. 



Fig. 67. —Section through a 
tooth and root cysts (after Hoff¬ 
mann). a, cyst wall; b, granula¬ 
tion tissue; c, necrotic pulp; d, 
carious portion of tooth. 




134 


THE ACCESSORY SINUSES OF THE NOSE. 


the lateral nasal wall will aid in arriving at a true perception of the 
condition. If a fistulous communication is present in the mouth, in¬ 
sert cannula and wash out, and, in the event of a cyst being at hand, 
the injected liquid will return from the same opening and not 
through the nose. If any doubt remains, a sound may be introduced 
until the superior wall is reached. The instrument is then with¬ 
drawn and measured on the face, and the point will not reach to the 
inferior orbital plate. A trocar can now be introduced and pierce 
the roof of the cyst. Water injected through the cannula will re¬ 
turn by way of the nose. 254 For differential diagnosis between 
cyst and sinusitis, see page 155. 

Treatment. 255-256 — Nothing but a radical operation will prove 
of the slightest benefit in these cases. The entire anterior wall 
of the cyst must be resected via the canine fossa, and, as the inner 
lining of the cyst is similar to mucosa of the mouth, no curettage is 
practised, but these structures allowed to unite, thereby forming 
one continuous cavity. After a longer or shorter lapse of time the 
cyst cavity becomes more or less obliterated and a perfect cure re¬ 
sults. 

This will be of value only when the cyst is very small; when it 
has assumed large proportions, a radical operation which resects 
all of its wall, thus obliterating it, and making a large counter open¬ 
ing into the nose, is absolutely indicated in order to bring about a 
definite cure. 

CASEOUS METAMORPHOSIS (VERKASUNG ). 83 ’ 257 ’ 258 

This consists of a fatty degeneration of the pus-corpuscles of 
the exudate with the formation of detritus from broken-down cells 
and a degenerated epithelium, the entire cavity of the antrum being 
thus filled with a solid or semi-solid mass of material having the 
consistency of i1 cottage ’’ cheese. 

This condition occurs in both acute and chronic empyema, but 
seems to be associated more particularly with the latter. The 
actual circumstances which lead on to this metamorphosis have 
never been satisfactorily explained, although it seems the explana¬ 
tion would lie in the fact that the mucous membrane has regenerated 

254. Cobb: Dentigerous Cysts. Laryngoscope, vol. 9, p. 397, 1900. 255. Andereya: 
Zur diagnose und Behandlung der Oberkiefercysten. Arch. f. Laryn., Bd. 20, S. 287,1908. 
256. Bautze: Beitrag zur Lebre von den Kieferzysten. Zeitschr. f. Laryn., Bd. 4, S. 99, 
1911. 257. Fischenich: Zur Frage der Verkasung des Kieferhohlenempyems. Verh. siid- 
deut. Lary., S. 526, 1902. 258. Bouvier: Kasiges Kieferhohlenempyem mit hochgradiger 
Verdrangung der Nasenscheidewand. Verh. d. ver. deutsch. Lary., S. 203, 1911. 



MAXILLARY SINUS. 


135 


sufficiently to throw off the disease. In any case the mucosa is no 
longer affected and the caseous mass occupies only the position of a 
foreign body. This is proved by the circumstance that it is only 
necessary to expel the mass by one or two lavages in order to bring 
about a permanent cure. 

Several conditions may be confused with, or result in, cheesy 
degeneration: 

1. The so-called cases of rhinitis caseosa are undoubtedly identi¬ 
cal with the above, except, in the former, cheesy masses force their 
way through the ostium into the nose. 

2. Purulent material which has been secreted above in the 
frontal or ethmoidal sinuses may flow into the antrum and, losing 
its moisture, assume inspissated and cheesy characteristics without 
in any way infecting the antral mucosa. 

3. A large mucoid cyst situated in the maxillary antrum may 
become solidified and by its growth cause certain pressure symp¬ 
toms wdiich lead to its discovery. (Fig. 65.) As only the con¬ 
tents would be brought to light, their similarity to the genuine 
caseous degenerated pus would warrant a diagnosis of “verka- 
sung.’ 9 The symptoms of this condition are those of a very mild 
case of maxillary sinusitis without free pus being visible in the 
nose on account of obstruction of the outlet. If the ostium is free, 
only a thin, serous discharge is frequently observed. On needle 
puncture it will at first be difficult to force through irrigating liquid, 
but, once started, cheesy masses with foetid odor will be expelled. 
It often requires several irrigations before the entire cavity is rid 
of this material, but after thorough evacuation no return of the 
condition need be feared. 


MUCOUS POLYPS. 

Polypoid growths and hypertrophies in conjunction with a puru¬ 
lent discharge are commonly met with in the maxillary sinus, more 
rarely associated with a serous discharge. Single polyps some¬ 
times attached to a long pedicle and unassociated with suppura¬ 
tion occasionally take their origin in the mucosa of the antrum. 
These usually find their way into the nasal cavity through an ac¬ 
cessory ostium or by causing an artificial accessory ostium by 
pressure ulceration through the pars membranacea. These polyps 
have been forced through the normal ostium by lavage following 
needle puncture. 2584 After emerging from the sinus they enlarge 


258a. Hirsch: Sitzungsberichte Wiener Laryng. Gesell. Monat. f. Ohrenhk., S. 657,1911. 




136 


THE ACCESSORY SINUSES OF THE NOSE. 


by growing backward, and may form a so-called solitary choanal 
polyp. (See page 66.) 

Treatment .—If the pedicle of the polyp is seized with a G-riin- 
wald forceps close to its exit from the ostium, and with a sharp, 
quick pull tom from its attachment to the sinus mucosa, the entire 
mass can be removed in toto. After such a removal they show 
little tendency to return. It is but rarely necessary to open the 
antrum through the canine fossa in order to permanently eradi¬ 
cate these large polypoid hypertrophies. 

MEMBRANOUS FORMATION IN THE MAXILLARY SINUS. 

Membranous deposits have been known to occur within the 
antrum independent of the presence of the diphtheric organism. As 
a rule, these are the results of traumatism, but may be of infective 
origin. Indeed, a case has been described in which the infection was 
so virulent as to ultimately lead to the death of the individual. 25815 

STONE FORMATION IN THE MAXILLARY SINUS. 

Six cases in all have been published of this rare occur¬ 
rence. 259 " 260 In all instances they cause symptoms of an acute max¬ 
illary empyema associated with considerable pain. The concrements 
varied in size from a pea to that of a walnut, were of reddish, 
brownish, or brownish-yellow color, being composed of lime salts, 
magnesia and phosphoric acid, and those that were sawed had no 
foreign body as a nucleus. No pathognomonic symptoms were 
present, nor any theories advanced as to their probable genesis. 

MUCOCELE OF MAXILLARY SINUS. 

Although isolated cases have been reported from time to 
time, 261-262 it is doubtful if these were true mucoceles. In every 
instance the contents were of decidedly fluid nature, while it is 
well known that those of the frontal sinus and ethmoid labyrinth 
contain a semi-solid, gelatinous substance. Under these circum¬ 
stances we would be justified in considering the former as a 
species of cystic enlargement. 

CHOLESTEATOMA FORMATION . 263 

This is characterized by the formation of a whitish or grayish 
mass within the sinus, distinctly lamellated, having an extremely 

258b. Kaufman: A Case of Membranous Infection of the Nose and Antrum, Resulting 
Fatally. Laryngoscope, p. 488, 1917. 259. OnoikofTer: Ueber Steinbilduns in der Kiefer- 
hohle. Arch. f. Lary., Bd. 20, S. 31, 1908. 260. Miihlen: Ein Fall von Steinbildung in 
der Kiefer und Keilbeinhohle. Arch. f. Lary., Bd. 21, S. 371, 1908. 261. Hastings: Muco¬ 
cele of the Nasal Accessory Sinuses. Ann. Otol., Rhin. and Laryn., n. 641, Sept., 1911. 
262. Lack (65). 263. Winckler: Zur Kausistik des Kieferhohlencholesteatoms. Zeit f. 
Laryn., Bd, 2. S. 251, 1910. 



MAXILLARY SINUS. 


137 


foetid odor and showing the presence of cholesterin crystals. Ac¬ 
cording to their origin they are divided into: (1) primary or true 
cholesteatoma; (2) secondary or false. 

1. The true cholesteatoma is undoubtedly of foetal origin, being 
due to some disturbance in the normal embryonal growth of the 
epidermis causing an untoward proliferation into the bones of the 
sinus, which acts as the nidus for the subsequent formation of the 
tumor. Deep-seated, involving underlying bone. 

2. The secondary or false cholesteatoma is caused by a meta¬ 
plasia of the normal cylinder epithelium of the sinus which takes 
place either direct from the diseased atrophic nasal mucosa or 
through a fistulous passage into the mouth. Superficial only af¬ 
fecting mucosa. 

The squamous epithelium grows through the opening until it meets with the 
inflamed cilated lining of the sinus. Being unable to unite with it, the epidermis 
grows in layer form, which soon finds insufficient nourishment and dies, another 
layer taking its place. In this way we can account for the laminated structure 
w)hieh has very aptly been likened unto the layersi of an onion. An external or 
fistulous opening is necessary in order for this to form. 

Symptoms. —The subjective disturbances occasioned by these 
bodies depend upon their size and the pressure exerted upon the 
sinus walls. When the cholesteatomatous mass fills the antrum 
bulging of the walls is noted, accompanied by intense pain. Tender¬ 
ness is marked over the entire area, with swelling of the lower 
lid. The nares on the affected side is filled with foetid pus and the 
inferior turbinate markedly congested. 

Operation will disclose a desquamative inflammatory mass of 
moist caseous lamellated epithelium and putrefying detritus with 
an extremely foetid odor, which, if a true cholesteatoma, will be in¬ 
timately adherent to the underlying bone; if secondary, will allow 
itself to be shelled out en masse. In the embryonal form unless 
all of the membrane is removed at the time of operation a recur¬ 
rence will certainly take place. 

The secondary form in contradistinction to the former, being 
caused by the sinusitis, will respond readily to operative treatment. 


Diagnosis. 


When a patient presents himself for examination and empyema 
of the maxillary sinus is suspected there is but one method which 
will give definite information: exploratory needle puncture. If 
pus appears either by aspiration * or by lavage, one is absolutely 


* Needle puncture with asniration m«y fail to bring out the secretion, 

pus has become inspissated or degenerated into caseous masses. For bacteno gi _ 
nations, however, it is most useful to obtain pure cultures of the infecting mi - 



138 


THE ACCESSORY SINUSES OF THE NOSE. 


certain that the antrum contained the purulent secretion. Whether 
the sinus itself secreted the product or whether it acted in the 
capacity of a reservoir for material which had been secreted in one 
or more of the overlying sinuses is a matter to be subsequently 
determined. Having ascertained that the maxillary sinus con¬ 
tained a pathological secretion, our next step is to find the cause 
and source of the pus. 

Examination of the Mouth .—A certain proportion of cases, 
twenty to thirty per cent., take their origin from caries of a tooth. 
This fact can almost always be elicited by the history and by 
visual and tactile examinations, and if this should prove to be the 
case, further delay is unnecessary, as our plan of treatment is 
clearly indicated. The method for examining the teeth is as fol¬ 
lows : With a small, heavy metal instrument, such as the handle of 
a laryngoscopic mirror, the upper teeth are gently tapped to 
elicit unnatural tenderness. If this is present in a certain tooth, it 
is probably due to a periodontitis around the root. Hot and cold 
water are next tried, and if hypersensitiveness is noted an inflam¬ 
matory condition of the dentin must be suspected. 263a Finally the 
positive pole of a weak electric current placed on the well-isolated 
tooth will substantiate our tests. If a pulpitis is present, con¬ 
siderable pain will be elicited from the diseased tooth; the others 
will react normally. If the tooth is dead, the current will cause no 
reaction. This must also be viewed with suspicion. If any doubt 
remains, an X-ray picture will speedily disclose the exact condi¬ 
tion of the alveolus and roots of teeth. 

Cowper Method of Treatment .—Extract the diseased tooth or 
root and bore an opening through the alveolus. If, on the other 
hand, in spite of our endeavors to find some past or present alveo¬ 
lar trouble, no signs or symptoms indicate that such was or had 
ever been the case, what is the next procedure to be adopted! The 
extraction of sound teeth for the purposes of diagnosis has long 
since then abandoned as obsolete, as it is manifestly absurd to 
sacrifice teeth when we have so many other and simpler means at 
hand, not to speak of the annoyance and inconvenience of the after- 
treatment should an empyema be found; therefore, to conclude our 
diagnosis, it is only necessary that the simple needle puncture with 
thorough lavage; be continued daily for perhaps a week, as this 

263a. Weski: Die moderne Zahnarztliche Diagnostik im Dienste der Rhinoloeie und 
Otologie. Zeit. f. Laryng., Bd. 3, S. 375, 1911. 



MAXILLARY SINUS. 


139 


procedure alone often brings about a complete cure; under which 
circumstances, no more pus being visible in the nose by rhinoscopy, 
the diagnosis is positively established that the maxillary sinus was 
not only primarily at fault, but that its lining mucous membrane 
was in a condition to quickly regenerate as soon as it had been re¬ 
lieved of its irritating pathological contents. 


It must be borne in mind that one or more of the overlying sinuses may 
have been primarily affected and later healed spontaneously, a certain amount of 
secretion having found its way into the antrum and there remaining. Under 
such circumstances one of two things, must necessarily happen. Either 1. 
The secretion remains dormant, gradually draining from the action of the cilia 
and the recumbent position of the patient, or 2. The secretion contains micro¬ 
organisms of a virulent form which quickly infect the mucous membrane of the 
antrum causing a typical case of acute maxillary sinus empyema. The author is of 
the opinion that the first condition frequently occurs, the second, but rarely, as it 
has been pointed out that the mucous membrane of the antrum may tolerate the 
presence of purulent secretion for a long period of time without itself becoming 
infected. Whether infection occurs, depends more upon the virulence of the con¬ 
tained micro-organisms than upon the quantity of pus involved. 

Should the continued lavage through the needle produce no 
change in the quality or quantity of the secretion, it is imperative 
that the anterior half of the middle turbinate be removed: (1) to 
enable one to ascertain whether the ethmoidal cells, or the frontal 
sinus, are secreting pus; (2) to lay bare the ostium of the maxillary 
sinus. 

During the interval while the wound is healing, nothing can be 
done except to continue the conservative treatment, because the 
bleeding which results from the lightest manipulations in the 
frontal region would so obscure the field as to make observations 
practically valueless. 

After the part has sufficiently healed (four or five days) make 
the needle puncture and lavage as usual, then wash the nares 
with normal salt solution and allow the patient to wait in an 
adjoining room for one-half to three-quarters of an hour. 

If an examination is now made and no pus is seen in the middle 
nasal passage, it is prima facie evidence that only the maxillary 
sinus has been affected. If, on the other hand, an appreciable 
quantity of purulent secretion is seen oozing out from the region 
of the hiatus semilunaris, it is definitely established that one or 
both of the overlying sinuses is also diseased, as it is manifestly 
impossible for the mucous membrane of the maxillary sinus to 


140 THE ACCESSORY SINUSES OF THE NOSE. 


secrete so freely that the entire cavity fills up and overflows in the 
short space of time that the patient remains in the waiting room. 

Our next problem is to determine whether both the maxillary 
and the fronto-ethmoidal * sinuses are affected or whether the 
fronto-ethmoidal alone, the maxillary merely acting as a reservoir 
for a portion of the purulent material which has been secreted by 
the mucous membrane of the former. This may be easily and 
quickly ascertained by the following procedure: Wash out the 
maxillary sinus as usual (preferably in the morning) after the 
nasal cavities have been cleaned, pack selvaged strips of gauze 
lightly but sufficient to exclude immediate penetration in the region 
of the ductus naso-frontalis, requesting the patient to return the 
same afternoon for further inspection. Remove the gauze and 
wash out the nares. The needle puncture is now made, and if the 
sinus has been the receptacle for pus secreted above, the injected 
solution will return unchanged. 

CLOSED EMPYEMA OF MAXILLARY SINUS. 

This condition is caused by partial or complete occlusion of the 
ostium, causing stagnation of the secretion. An almost infallible 
sign of this condition during an attack of maxillary sinusitis is 
bulging of the pars membranacea in the middle nasal passage, 
without any trace of secretion being visible in the nose. A tumor 
in the maxillary sinus could also simulate this condition. 

Adjuncts to Diagnosis. 

Transillumination.— This method is applied in the following 
manner: The room must be as dark as possible. After the eyes 
have become accustomed to the darkness, a small electric globe is 
placed in the patients mouth (care being taken to remove false 
teeth if present), and the current applied after the lips are com¬ 
pressed. With a rheostat the illumination should be gradually 
brightened to the full capacity of the lamp. Bright spots should 
appear in the canine fossa (Plate 3) and in the infra-orbital 
regions; the pupils are also dimly lighted. 264 Any differences in 
the illuminations of the sides must be quickly noted; also the sub¬ 
jective symptoms of the patient. This procedure should be re- 

*The term, fronto-ethmoidal, is used because the frontal sinus is rarely if ever alone 
affected; some of the anterior ethmoidal cells invariably are sympathetically diseased. 
(See Anatomy of Frontal Sinus.) 

264. Brown, Kelly: Transillumination of the Antrum of Highmore. Brit. Med. 
Journ., vol. 1, p. 650, 1905. 



MAXILLARY SINUS. 


141 


peated several times by turning on the light in order to confirm as 
far as possible the first impressions. If strongly marked unilateral 
shadows occur, it is presumed that empyema is present on that side. 

Mechanism of Transillumination , 265 —When the current is 
applied, the lamp being in the mouth, some of the rays enter 
the maxillary sinus through the alveolus, but the majority first 
enter the nasal chambers and are reflected through the lateral 
nasal wall into the antrum (chiefly through the inferior meatus). 
If sufficient illumination is present the rays will then penetrate 
the superior or orbital wall and impinge upon the retina, thus 
giving the subjective sensation of light to the patient. 

Actual Cause of Shadow Formation. —Unilateral shadows un¬ 
fortunately do not always mean that a disease exists on that side. 
Inequalities in the anatomical formation of the bone are among the 
chief causes of error. It is now a matter of common knowledge 
that equalized transillumination of the maxillary region is the 
exception rather than the rule. 

Purulent secretion en masse is supposed to arrest the rays of 
light, thereby causing more or less well-defined shadows on the 
affected side, depending upon the thickness of the secretion. As 
a matter of fact, this cannot be depended upon, as it has been 
demonstrated that an antrum filled with pus may be as translucent 
as the opposite unaffected side. What, then, causes the area of 
darkness in diseased sinuses? This question is best answered by 
the following hypothetical case: A patient shows maxillary sinus 
empyema on transillumination. A needle puncture is made and a 
large quantity of purulent secretion is expelled. Again the trans¬ 
illumination test is applied, and the shadow remains as well defined 
as before the pus was evacuated. After a period of appropriate 
treatment the affection is cured. Another test is made and the 
sinus appears as light as the fellow on the opposite side. Our 
conclusions are now obvious. The shadow must have been caused 
by the diseased mucosa, for, after resolution occurred, the opacity 
at once disappeared. This has been the experience of every 
rhinologist who has made extensive use of this adjunct to 
diagnosis. 265 ' 268 

Value as to Reliability .—From what has been said, the de- 

265. Logan Turner: The Accessory Sinuses of the Nose, p. 110, Edinburgh, 1901. 
266. Schwartz: Ueber d. diagnost. wert der elekt. Durchleuchtung. Beit. z. Klin. Chir., 
Bd. 14, 1895. 267. Ziem: Nochmals die Uberschatzung d. Durchl. d. Kieferhohle. 

Mon. f. Ohren., S. 155, 1895. 268. Lambert Lack (65), p. 303. 



THE ACCESSORY SINUSES OF THE NOSE. 


142 

duction is clear that we must exercise the greatest circumspection 
in making a positive diagnosis from the findings of transillumina¬ 
tion alone. As a matter of fact, it should never be done. We 
have always at our command a simple harmless procedure which 
requires but a moment to carry out and is absolutely reliable: 
the needle puncture. This is particularly applicable when the 
only symptom of antrum disease is unilateral darkness. 

The transillumination test may then be said to be, as far as 
the antrum is concerned, an important adjunct to corroborate the 
diagnosis after all other examinations have been made. If the 
symptoms point toward maxillary sinus disease and the test is 
positive, well and good; if negative, it is no proof of the non¬ 
existence of the affection. 

Rontgen Ray.— While not so valuable as in the frontal sinus, 
the X-ray gives usually reliable information as to the condition of 
the sinus mucosa. In those cases where disease is present the 
contour of the sinus is not so distinctly marked as in the healthy 
cavity. The plate shows a shadow on the diseased side as well 
as a blurring above the sinus borders. It must be borne in mind 
that when a copy is printed from the negative, the diseased por¬ 
tion will show darker instead of lighter than the healthy side. 

Suction or Negative Pressure.— The rationale of this method 
is to close the choanae by allowing the patient to articulate a con¬ 
tinuous K, then applying suction to the external nares, thus 
causing a condition of negative pressure in the nose and forcing 
any secretion out of the ostia which may be contained in the sinus. 
This has been of but little value in our hands. Even after the 
nose had been thoroughly irrigated there always seemed to be a 
certain amount of secretion drawn into the nose where this method 
was successfully applied. 

It was, however, by no means certain that this secretion was 
drawn from the sinuses, as the probabilities are that it was hidden 
in the deeper interstices of the ethmoid capsule. In the vast ma¬ 
jority of instances it was impossible to obtain complete closure 
of the posterior nares, and when this did occur there nearly 
always appeared to be some hitch in the technique, until the advent 
of the Sorrenson apparatus which appears to have overcome the 
fallibilities of the earlier instruments. In applying this method 
care must be exercised not to apply too great a degree of negative 
pressure, otherwise, a most unpleasant feeling in the ear, if not 
actual injury to the drums, will be produced. 


MAXILLARY SINUS. 143 

Symptoms. 

Acute .—1. Feeling of distention and pressure: These symp¬ 
toms are practically always present in the first stages of the acute 
form. They are due more to swelling and hypersemia of the max¬ 
illary mucosa than to the internal pressure of the pent-up secretion. 
When present, the nares of the corresponding side is occluded and 
intensely congested, so that even needle puncture, followed by 
lavage, has little influence upon it. Anterior wall often sensitive 
to pressure. 2. Pain may be present or absent, depending largely 
upon the degree of inflammation present in the sinus. 269 It may 
assume the character of a distention, or, what is more often the case, 
that of neuralgia. In acute empyema of dental origin the pain is 
apt to be particularly severe if a periostitis of the alveolus has been 
the cause of the suppuration. 

Pain is particularly noticeable when stagnation of secretion with pressure 
occurs. That this is often the true cause of the pain in contradistinction to swell¬ 
ing of the mucosa is proved by the immediate relief experienced on irrigation of the 
sinus with expulsion of its contents. 

Curiously enough, the neuralgia is not confined over the supe¬ 
rior maxillary area, but its seat of predilection is over the orbit 
of the affected side. 270 Supra-orbital pain may be the only symp¬ 
tom, and of such persistence as to simulate frontal sinus disease. 
Indeed, such cases have by their persistency been mistaken for 
this affection, with the result that the frontal sinus was needlessly 
opened. This is an object lesson which requires no comment. 
Pain in the teeth of the upper jaw on the diseased side is occa¬ 
sionally present, particularly if the empyema was of dental origin. 
Sometimes only a peculiar uncomfortable feeling is noted in the 
teeth, as though one particular tooth was loose or longer than 
its fellows. The headache, whatever its character, is usually in¬ 
tensified by stooping, coughing, sneezing, etc., and, in fact, by any 
condition which produces a sudden jarring of the head or body. 
Indulgence in alcohol and tobacco increases the discomfort. 

After the disease has lasted several days and become sub¬ 
acute the pain, if a prominent symptom, becomes remittent, the 
exacerbations depending upon the quantity of purulent material 
secreted. Regarding pain located directly in the sinus, this only 
occurs when severe local changes are present, such as inflamma- 


269. Menzel: Zur Symptomatologie der Kieferhohlen-empyem. Monat. f. Ohrenhk., 
No. 6, 1905. 270. Killian (44), p. 1024. 





144 


THE ACCESSORY SINUSES OF THE NOSE. 


tion of the underlying bone (periostitis) or ulcerations of the 
soft parts. 

Secretion .— a . The secretion in acute maxillary sinusitis is not 
formed at the inception of the disease, but makes its appearance 
after the first day or two. Its profuseness depends largely upon 
the causative factor as well as its constituency; thus, empyemas of 
nasal origin do not, as a rule, secrete so freely as those of 
dental origin. The character of the secretion may range from 
serous to purulent and even sanguino-purulent, depending upon the 
character of the disease. The pus from acute sinusitis of dental 
origin is apt to be fetid and contain caseous masses. 

b. Place of appearance: This is usually in the middle nasal pas¬ 
sage, over the uncinate process beneath the middle turbinate and ap¬ 
pearing on the anterior third of the inferior turbinate and often on 
the septum directly opposite. It is much more likely to appear in 
this place in acute inflammation than in the chronic form, for in 
the former there is little likelihood of pathological changes having 
taken place to dam off and guide the purulent material to other 
places. However, in seeking for this symptom due consideration 
should be made for the position of the head, anatomical formation 
of the nose, and consistency of the secretion. The appearance of 
the secretion is not always constant, as at certain times during the 
day the nose may be entirely free from any trace of pus. This 
is explained by the fact that for some reasons not well understood 
the ostium and drainage passages suddenly become patulous, 
allowing the full escape of the sinus contents into the nose. In 
these cases this often occurs in the form of a siphonage, thus 
emptying in a short space of time. The usual time for this to 
occur is immediately after arising, so that when the patient comes 
under observation during the morning office hours often but little 
secretion can be seen. A history of a discharge can always be ob¬ 
tained, as the patient complains of the enormous quantity which he 
is obliged to expel from the nose every morning. 

Nasal Symptoms. —The nares on the affected side is in a con¬ 
tinued state of hyperaemia with more or less occlusion. The nasal 
mucosa is hypertrophied, particularly on and around the uncinate 
process. The hyperplasia in this locality is occasioned by the 
continual irritation from the overflowing secretion as well as by 
continuity through the ostium from the antral mucosa. 

The sense of smell is diminished or entirely obliterated, due 
to either the hyperplasia preventing the odorous substances from 


MAXILLARY SINUS. 


145 


reaching the olfactory space, or to the secretion covering the ter¬ 
minal filaments of the olfactory nerve. In severe cases where the 
hyperaemia is marked, passive oedema of the eyelids and cheeks is 
often observed (caused by inflammation of the collateral venous 
circulation). 

It will depend largely upon the general configuration of the 
middle nasal passage, particularly upon the position of the middle 
turbinate, as to what may be noted by anterior rhinoscopy. 

The classical symptoms are pus appearing from beneath the 
anterior end of the middle turbinate, flowing down over the infe¬ 
rior turbinate, which immediately reappears on wiping away with 
a pledget of cotton. When the middle turbinate lies against the 
septum, it frequently occurs that no trace of pus is to be seen in 
the middle nasal passage, but in the superior nasal passage a 
marked quantity is in evidence. This is caused by capillary 
attraction, the purulent secretion flowing slowly down on the an¬ 
tral side of the middle turbinate reaches the inferior edge and is 
attracted upward by the mucous membrane of the septum. On 
first sight this is apt to be confusing and lead the examiner to 
suspect empyema of one or more of the sinuses of the second 
series; however, when this secretion is removed it will not imme¬ 
diately return, thus proving that it is not the end stream from a 
reservoir. If the middle turbinate lies somewhat removed from 
the lateral nasal wall and the processus uncinatus is not very 
broad, this symptom will always be present. Unfortunately, this 
is hut seldom the case. The mucous membrane of the processus 
uncinatus, bulla ethmoidalis and middle turbinate is almost always 
swollen and cedematous, and these parts usually impinge upon one 
another, thus closing the anterior outlet. As a consequence the 
continually forming secretion in the maxillary sinus must find an 
outlet, which it does, backward into the choanae, through a passage 
between the middle turbinate and lateral wall of the nose. 

General Disturbances. —These usually take the form of those 
which accompany any acute local disturbance and correspond 
proportionately in severity. Fever and chills are, perhaps, in the 
beginning the most prominent symptom. In mild infections these 
may be so slight as to pass almost unnoticed, while in the severer 
types they are so marked as to confine the patient to bed. 

Generally speaking, the individual suffering with acute max¬ 
illary sinusitis, even though able to be about, has the appearance 
10 


14G 


THE ACCESSORY SINUSES OF THE NOSE. 


of a sick man. Generally restlessness during the day and sleepless¬ 
ness during the night are prominent symptoms. Gastric and in¬ 
testinal disturbances, especially when the secretion has a tendency 
to flow into the choana and be swallowed, which assume the form 
of nausea and eructations of gas, are prone to occur. Periton¬ 
sillitis is not an uncommon incident; in fact, the prevailing symp¬ 
toms often direct one to believe some throat affection is the cause 
of the sickness. 

Complications. 271 — These are exceedingly rare, but for the 
sake of completion the following, which have from time to time 
been reported must be mentioned. 

Ascending Ostitis .—This dangerous condition seems particu¬ 
larly prone to accompany maxillary sinusitis of dental origin, 2714 
and is characterized by a slowly ascending purulent affection of 
the entire structures of the natural walls which soon involves the 
frontal and ethmoidal sinuses. This condition can only be success¬ 
fully combated by an immediate and radical external operation. 

Orbital .—CEdema of the eyelids: This has been previously men¬ 
tioned and is due to inflammatory products finding their way into 
the ethmoidal veins. CEdema of the retro-bulbar cellular tissues 
causing exophthalmos 272 without the formation of a purulent col¬ 
lection. 

Exophthalmos due to the formation of an orbital phlegmon. 275 
(Fall 3.) Partial or total temporary blindness, which disappeared 
after varying intervals, have been reported. 273 These, according 
to Killian, were due to pressure of the cedematous tissues on the 
optic nerve and central artery of the retina. 

Meningitis and brain abscess: Intracranial complications are 
rare owing to the removed anatomical situation of the maxillary 
sinus from the cerebral structures. That such complications, how¬ 
ever, are possible have been shown by several investigators. 274 " 2754 
Pyaemia may also result from the products of suppuration, find¬ 
ing themselves in the general circulation. 276 


271. V lllemonte-Laclergerie: Complications oculo orbitaires des sinusites maxilla ires. 
These de Bordeaux, 1906. 271a. Paunz: Ueber die Komplikationen des dentalen Kieferi 
hohlenempyems. Verh. des III. Internat. Laryngo-Rhinologen Kongresses, Berlin S 
287, 1911. 272. Pagenstecker: Beitrage z. Aetiol. u. Therap. der retrobulbaren Zel’lge- 

websentzundung Arch; f. Augenhk., Bd. 13, S. 138, 1884. 273. Halstead: Empyema of 
Right Maxillary, Ethmoidal and Sphenoidal Sinuses, with Sudden Blindness of the Left Eye 
Operation. Recovery of Sight. Archives of Otology, June, p. 223,1901. 274. Dmochowski *: 
Entziindliche Processe des Antrum Highmori. Arch. f. Lary., Bd. 3, S. 255 1895 275 

Manasse: Ueber orbitale und cerebrale Komplikationen bei akuten Nebenhdhleneiterun- 
gen. (Fall 2.) 1 Ver d. ver. deutsch. Lary., S. 189, 1911. 275a. Leegaard: Intracranial 
Complications from Disease of the Sinus Maxillaris. Ann. of Otol., Rhin. and Laryng p 
140, March, 1919. 276. Zange: Ueber Pyseme nach Kieferhohleneiterung. Zeit. f. Ohrenhk 
Bd. 60, 1910. 




MAXILLARY SINUS. 


147 


Chronic Empyema .—The symptomatology of this affection is 
peculiar in the wide range of degree from mild to severe which it 
may assume; as an example, the symptoms can he so slight as to 
even fail entirely, the patient being unconscious of any sinus trouble 
until accidentally discovered. This is fortunately the exception 
rather than the rule, as careful examination in these cases will usu¬ 
ally elicit some symptoms which will ultimately lead to the correct 
diagnosis. On the other hand, the transition from the acute to the 
chronic stage may take place without perceptible abatement in the 
subjective sensations, the course of the disease being, so far as the 
symptoms are concerned, to all intents and purposes, acute. 

Pain .—Actual pain in the sinus is usually absent, neither do we 
find the sensation of fulness nor sensitiveness to pressure as in the 
acute form. (When the sinus is filled with dilated cysts or mucous 
polyps the sensation of distention is sometimes present.) Head¬ 
ache in some form is a common symptom, the most frequent being 
supra-orbital neuralgia, although in severe cases, particularly when 
partial stagnation occurs, the pain is apt to embrace the corre¬ 
sponding half of the head. (Killian believes the pain is due, not 
only to the irritation of the trigeminal nerve endings in the mucosa, 
but to the direct irritation of the main trunks.) 

The pain, however, is variable and for a thorough description 
the cases must be divided into (1) mild; (2) moderate; (3) severe. 

1. In mild cases the pain is- absent or at most takes on the 
character of a full tense feeling in the superior maxillary region of 
the affected side. Often enough there are absolutely no subjective 
symptoms from which one could draw an inference that the max¬ 
illary sinus was affected. No tenderness, no swelling, teeth on 
both sides apparently sound, and it is not until exploratory needle 
puncture has been made that the diagnosis is established. 

2. Moderate cases: The pain is similar to attacks of neuralgia, 
occurring at intervals, and is characterized by its indefinite local¬ 
ization, being but rarely confined to the superior maxillary region. 
In conjunction with the full tense feeling, sharp shooting pains 
occur in the infra-orbital nerve and frequently in the supra-orbital 
region, and, indeed, may be entirely localized to the latter. 269 The 
patient usually complains of a dull, indefinite feeling of tenseness 
in the diseased side of the head, with intermittent twinges of 
neuralgia over the entire side of the face and forehead. This pain 
is usually worse late in the morning and towards evening gradu¬ 
ally remits. This is due to the fact that partial drainage of the 


148 


THE ACCESSORY SINUSES OF THE NOSE. 


cavity takes place as in the other sinuses. The pain and discomfort 
of the patient is markedly increased by indulgence in alcohol or 
tobacco. Occlusion of the nares on the affected side is intermit¬ 
tently present, being especially marked when the sinus is full of 
pus, just before the emptying process occurs. The explanation of 
this lies in the fact that the pressure of the contained secretion 
causes a hyperaemia on the lateral nasal wall, thus causing the 
mucosa to swell and at the same time stimulating the swell bodies 
in the inferior and middle turbinates. As soon as the sinus empties 
itself these structures shrink and the nose again, becomes free. 

3. Severe cases: One would suppose that when the mucous 
membrane of the sinus had undergone great degeneration with 
perhaps underlying caries of the hone, the acute local pain would 
be well marked. 

While this is true in the main, nevertheless exceptions can and do occur, as is 
exemplified in the following* cases: 

Case 1.—Mrs. B. Chronic maxillary sinusitis, severe pain on corresponding 
side of head, almost continuous, little discharge, general symptoms of debility. 
Radical operation, areas of polypoid degenerated mucosa, little non-fcetid secretion. 

Case 2.—Mrs. P. Chronic maxillary sinusitis. Never any pain, profuse dis¬ 
charge, principal complaint of patient subjective foetid odor in nose. 

Radical operation, sinus filled with extremely foetid pus, mucosa acutely in¬ 
flamed and degenerated. 

On comparing these cases, one is at once struck w T ith the dissimilarity of the 
pain in ratio to the inflammatory condition of the mucosa. 

The indefinite character of the pain is still marked, but the feel¬ 
ing of tenseness, with sudden, lightning-like paroxysms of neu¬ 
ralgia, is so intensified as to become almost unbearable. These neu¬ 
ralgic attacks are not confined to the diseased side, but are often 
complained of on the opposite side, particularly over the course of 
the infra-orbital nerve and in the parietal region. Occlusion of the 
nares is marked and more or less constant, and around the vestibule, 
particularly of the affected side, eczematous eruptions are to be ob¬ 
served. The tense feeling is continually present, the patient seldom 
being entirely free from some discomfort, as in the preceding con¬ 
ditions. Even after a thorough lavage the pain is not relieved. 277 
Alcohol and tobacco are absolutely untolerated. Any sudden jar¬ 
ring, stooping over, straining at stool—in fact, any conditions 
which cause congestion of the head—will cause unsupportable 
anguish. 

277. Hajek: Der Kopfschmerz bei Erkrankungen der Nase und deren Nebenhohlen, 
No. 11, S. 418, 1899. 




MAXILLARY SINUS. 


149 


The feeling of anguish so completely covers the affected side 
that one is often at loss to definitely state whether several and not 
one particular sinus is affected; this tension, in other words, is so 
wide in its scope as to he not at all pathognomonic of maxillary 
sinusitis. 

Secretion .—The character may he serous, mucoid, mucopurulent, 
or purulent, depending upon the virulence and intensity of the dis¬ 
ease. Foetid discharge has usually been considered to be pathog¬ 
nomonic of dental origin. This is not always the case, as any con¬ 
dition which will predispose to putrefaction (stagnation) will ac¬ 
complish this end. When occlusion of the ostium with stagnation 
occurs, the white blood-corpuscles sink to the bottom and putre¬ 
faction sets in. 

The classical place of appearance of the secretion is, naturally, 
where the ostium empties into the nasal chamber—the middle 
nasal fossa beneath the anterior end of the middle turbinate. The 
various irregularities in the nose, deviations of the septum, polyp 
formations, hypertrophies of the uncinate process and middle tur¬ 
binate, all tend to direct the course of the secretion out of the ordi¬ 
nary channels; therefore, it is not an uncommon occurrence to see 
pus in untoward and unexpected places. The amount of the secre¬ 
tion varies according to the intensity of the inflammation, as well as 
to its place of appearance. A small quantity, for instance, ap¬ 
pearing anteriorly will be noted by the patient, while a large 
amount might escape by the way of the posterior nares and either 
be swallowed or expectorated and cause little or no attention. When 
we consider that hypertrophy of the middle turbinate, causing the 
anterior end to press tightly against the lateral wall, polyps, etc., 
may absolutely prevent the pus from appearing anteriorly, thus 
forcing it backward into the choana, the importance of this in judg¬ 
ing the amount of secretion can not be overestimated. Crust for¬ 
mation in the nasopharynx is also a diagnostic sign of no little im¬ 
portance. The patient may deny having any other secretion ex¬ 
cept that which would naturally result from a slight chronic cold, 
yet admit that he was obliged every morning, by forcible sniffing 
and hawking, to remove large crusts from the nasopharynx which 
had collected during the night. This crust formation is, of course, 
nothing more than dried, inspissated, purulent secretion which had 
accumulated during the sleeping hours. The most reliable method 
of determining the approximate amount of secretion is to ask the 
patient how many handkerchiefs he is obliged to use during the day. 


150 


THE ACCESSORY SINUSES OF THE NOSE. 


Constancy of the Flow of Pus .—While in the majority of instances signs of pus 
are always to be found in the nose, nevertheless it sometimes occurs, particularly 
early in the morning, that absolutely no traces of a pathological secretion are to be 
seen by anterior rhinoscopy. This can be accounted for as follows: While the pa¬ 
tient is reclining during the night on the unaffected side, the ostium of the sinus is 
naturally in its lowest position. The secretion begins gradually to filter out and by 
morning a considerable quantity of it lies in the nasal cavities. If it is thickened and 
inspissated, a mechanism of siphonage now occurs whereby the free secretion already 
in the nose will flow back into the choanae, drawing with it a certain quantity out of 
the sinus. The patient, by rasping and hawking, finally dislodges this, expectorating 
the mass, and on presenting himself for examination will show no traces of secretion. 

Periodicity of Emptying .—It lias been shown, under the general 
heading of symptomatology, that the purulent secretion formed in 
the sinuses is not continually flowing into the nose like a leaking 
faucet, but intermittently appears drop by drop. This is but a 
natural condition when we consider that the sinus contains but one 
ostium,* and for every drop of secretion which is expelled a corre¬ 
sponding volume of air must take its place. As the air must enter 
by the same passage from which the fluid escapes, atmospheric 
pressure must exert no inconsiderable influence on the regular out¬ 
flow of the sinus contents. This is particularly true of the maxil¬ 
lary sinus, for it must be remembered that its normal ostium lies at 
the superior extremity, therefore in the most unfavorable position 
for constant drainage, while in the frontal sinus and ethmoid cells 
the accumulating secretion may continually escape, as the outlets 
lie at the lowest position. The viscidity of the purulent material is 
another factor in this condition, and it not infrequently happens, 
particularly in maxillary sinus disease, that when the sinus cavity 
becomes filled and overflowing occurs, most of the contents is 
siphoned out, leaving the sinus practically empty. (It must be re¬ 
membered that the ostium of the maxillary sinus lies at the supe¬ 
rior extremity of the cavity; therefore, in the worst possible posi¬ 
tion for favorable drainage.) This siphonage takes place while 
the patient’s head is not in the upright position; therefore, usually 
at night, and accounts for the hawking and clearing the throat, which 
is such a frequent symptom and so often complained of. 

Changes in Consistency .—It is not an infrequent occurrence in 
chronic maxillary sinusitis to note the secretion becoming thick and 
viscid. This is noted particularly in acute colds, during which time 
it is very profuse, while in the intervals no especial trouble is ex- 


*The accessory ostium appearing in only ten per cent, is not reckoned. Should, 
however, one be present, the entire physical law of drainage is changed, as the second 
opening acts as a vent to the normal one, thereby allowing the free and continued outflow 
of the secretion. 



MAXILLARY SINUS. 151 

perienced. These changes are due to an acute exacerbation of the 
chronic condition, which runs its course, leaving the old affection 
in its original condition. 

The structures of the lateral nasal wall may, in recent cases, 
show congestion, but as a rule, hypertrophic and polyp formations 
are found in the more chronic forms. Unilateral hyperaemda, 
when present, is due to the congestion of the veins from the pressure 
of the exudate in the antrum. The seat of the polyp formation is 
along the free border of the processus uncinatus, around the maxil¬ 
lary ostium, and on the external border of the middle turbinate; in 
other words, along the course of the escaping secretion. (See sec¬ 
tion on Relation of Polyps to Empyema, p. 63.) Hypertrophy oc¬ 
curs particularly on the uncinate process * and anterior extremity 
of the middle turbinate. Unilateral hypertrophy in these positions 
is a certain sign of underlying sinus affection. Unilateral occlusion 
from hyperaemia is always relieved by ridding the sinus of its 
pathological contents. 

NASOPHARYNX AND LARYNX. 

Symptoms affecting these parts are so common in maxillary 
sinusitis that they are practically always concomitant. Some¬ 
times they are the principal symptom, and patients not infre¬ 
quently present themselves for treatment for some fancied throat 
affection when the entire trouble is in the antrum. The symptoms 
take the form of dryness, particularly accentuated in the morning, 
hawking and clearing the throat immediately on arising to rid them¬ 
selves of the accumulated masses of half-dried secretion which has 
formed during the night. Granular pharyngitis is a sequela of 
these formations, and it is often confined to one side of the posterior 
pharyngeal wall (pharyngitis lateralis). That form of scleroid 
pharynx due to the constant drying of secretion may be easily 
identified, as it gradually loses itself toward the larynx, while to¬ 
ward the choana it is more intensified. Laryngeal disturbances, 
such as hoarseness, partial aphonia, and even complete loss of 
voice, have from time to time been noted. 

DISTURBANCES IN OLFACTION. 

Neurotic disturbances of this character may take the form of 
total or partial anosmia, due to the passive or active occlusion of 

*The lateral nasal swelling of Kaufman (Mon. f. Ohren., S. 13, 1890) is the swollen 
lip of the hiatus semilunaris, the middle turbinate being rolled above. This swelling often 
gives one the impression of its being the middle turbinate. 







152 


THE ACCESSORY SINUSES OF THE NOSE. 


the olfactory fissure through swelling of the mucous membrane, 
polyps, or collections of purulent material. 

A much commoner disturbance is that of subjective perception 
of foetid odors (cacosmia). This is usually intermittent, and par¬ 
ticularly noticeable when the patient suddenly sniffs. The usual 
complaint is that of something putrefying in the nose, which seems 
to be worse at intervals. A sign of absolute diagnostic importance 
is the subjective intensification of this odor when air is forced 
through the sinus on needle puncture. The patient suddenly re¬ 
marks that the source of the odor has been reached. Contrary to 
the general opinion, I do not believe this factor results from the 
escape of the purulent secretion into the nose, but rather to the 
putrefactive gases which continually form, but only intermittently, 
and, after a certain volume collects, force their way through the 
ostium into the nose. I have often observed, while forcing air 
through after needle puncture, that the odor exudes from the nose 
so as to be noted at some distance from the patient. This has 
taken place without the slightest trace of any secretion appearing 
in the middle nasal passage. 

While this cacosmia is particularly associated with empyema of dental origin, 
it is by no means pathognomonic of this affection, as it often appears with maxillary 
sinusitis of nasal origin as well as ethmoidal suppuration. 

Indirectly, cacosmia may be far-reaching in its effects, as it 
often turns the patient against food or nourishment of any kind, as 
well as directly affecting the nervous system, causing depression 
and even more serious psychological disturbances. 

NERVOUS MANIFESTATIONS. 

Neurotic disturbances are sometimes present. They do not 
depend so much on the actual severity of the disease as upon the 
temperament of the individual, although, of course, the more viru¬ 
lent the disease, just so much more liability for the predominance 
of mental disturbances. Certain neurotic individuals note with 
great exactness the slightest abnormality from their usual con¬ 
dition ; others, on the other hand, are not conscious of even consid¬ 
erable unwonted discharge. Various psychical alterations may 
occur during the course of the disease, as have been enumerated in 
the general chapter on symptoms, but with the maxillary antrum 
they are by no means so prevalent as with the other sinuses which 
lie in closer juxtaposition to the brain. 

Epilepsy has recently been reported as having been due to pus 
in the maxillary sinus. 277a The convulsions promptly disappeared 

277a." Keeler: Idiopathic Epilepsy Found to be Due to Empyema of the Antrum of 
Highmore. Operation and Recovery. Laryngoscope. August, 1919. 



MAXILLARY SINUS. 


153 


after the sinus had been cleared of its purulent contents and the 
mucosa freed of its infection. 


COMPLICATIONS. 

1. Caries of the Osseous Walls of the Antrum, with Rupture 
into the Neighboring Parts, with Abscess Formation. 278 —This 
may occur in the anterior wall, 270 posterior wall, 269 ’ 280 hard 
palate, 281-282 nasal wall, 283 and orbital wall. 284 

It is not necessary that caries occur to have a phlegmonous 
inflammation in the region outside of the antrum, as the inflam¬ 
mation can travel through the foramina in the bone along the nerves 
and vessels. This is particularly true of the openings for the 
accessory veins which pierce the antral wall in various places. 

Orbital abscess is, of course, the most dangerous of these, for it 
can easily lead on to intracranial infection. This can occur either 
through the optic foramen or through the orbital roof. 285 Orbital 
complications through the maxillary antrum run precisely the 
same course as those from the other sinuses. If exophthalmos 
occurs, the direction of the protrusion, at least in the beginning, 
may be directed upward and forward, in contradistinction to that 
from the anterior ethmoidal and frontal sinuses. Meningeal com¬ 
plications without previous orbital infection rarely occur, owing 
to the fact that no anatomical connection exists between the 


maxillary sinus and the cranial cavity. Certain isolated cases, 
however, have been reported, the one from Claoue 286 being of 
especial interest. 

2. Dilatation of the Antrum.— This condition, occurring as a 
complication of chronic empyema, is dependent upon an absolute 
occlusion of the ostium, with free secretion from the mucosa. 287 
Naturally, the nasal wall (pars membranacea) will be the first to 
yield to the internal pressure, the other walls following in various 
degrees, as the case might be. 


Killian 288 and Gerber 289 insist upon the comparatively frequent occurrence of 
this condition. My experience previously coincided with that of Hajek, in that it 

278. Noltenius: 37 Falle von seroser Erkrank. d. Oberkieferhohle. Mon f. Ohrenhk., 
S 114 1895 279. Paunz: Ueber die Komplikationen des dentalen Kieferhohlenempyems. 

Arch. f. Lary., Bd. 25, S. 449, 1911. 280. Dmochowski (27), Fall 25. 281. Grunwald 
(91) S. 120. 282. Panzer. Wien. klin. Wochenschr., S. 361, 1896. 283. Killian: Die 

Krankheiten der Kieferhohle. Heymann’s Handbuch, Die Nase, S. 1044, 1900. 284. 

Cohen and Reinking. Beitr. z. Augenhk., H. 78, Fall 16, 1911. 285. Panas: Empyeme 
du Sinus Maxillaire Complique d’osteo-periostite orbitaire avec perforation de la voute; 
abces du lobe frontal et atrophie de nerf optique. Mort. Arch. d’Ophthal., T. 15, p. 129, 
1895. 286. Claoue: Empyeme du Sinus max. gauche Infection aigue secondaire des 

sinus sus-naseaux gauches. Accidents meningitiques. Mort. Revue de laryng., T. 15, 
p. 805, 1895. 287. Yankhauer: An Unusual Case of Empyema of the Antrum of High- 
more. Medical Record, Aug., p. 256, 1903. 288. Killian (283), S. 1047. 289. Gerber. 
(78), S. 65. 




154 


THE ACCESSORY SINUSES OF THE NOSE. 


did not occur, but a case recently coming- under my care showed irrefutable signs of 
marked dilatation, which was substantiated by the X-ray negatives, and, as the his¬ 
tory and subsequent operation proved it to be chronic maxillary sinusitis, the theory 
of non-dilatation of sinus cavities, at least so far as I am concerned, is no longer 
tenable. 

The bulging of the pars membranacea * in the middle nasal 
passage is a frequent occurrence, even though the ostium is not 
absolutely occluded. This structure, being composed of two layers 
of mucous membrane, is quite elastic and returns to its normal 
position as soon as the internal pressure is relieved. Dilatation 
from internal pressure of polyps, though a rare condition, is occa¬ 
sionally met with. The polypoid mucosa filling the cavity con¬ 
tinues to enlarge, thus actually forcing the healthy osseous walls 
to yield. The pars membranacea is the first to give way; therefore, 
occlusion of the nares on the affected side is always present. 

3. Empyema Complicated ok Caused by Cyst Formation.— A 
tooth cyst may rupture into the antrum, causing or simulating true 
empyema. Under these circumstances, dilatation of the bony walls 
is the rule, and it is possible that many cases of supposed dilata¬ 
tion from empyema have been confounded with this condition. 

Differential Diagnosis .—It is a rare occurrence that one is 
obliged to distinguish between certain local conditions in the supe¬ 
rior maxilla and antral empyema. There are two other conditions, 
however, which might cause, at first glance, some confusion, i.e., 
dental cysts and malignant neoplasms (breaking down and ulcera¬ 
tion of a sarcoma). The following differential tables will show 
wherein they differ: 


Differential Diagnosis. 


MALIGNANT NEOPLASMS. 


EMPYEMA OF MAXILLARY SINUS. 


Bulging of walls. 

Softening of walls. 

Spontaneous loss of teeth. 

Secretion most foetid. 

Blood-stained fibres of tissue in the 
secretion. 

New growth appears in nares. 

Glands of neck involved. 


No bulging. 

No softening. 
None. 

May not be foetid. 
None. 

No new growth. 
No involvement. 


My personal stand in the entire subject of dilatation of the sinus walls from the 
internal pressure of an empyema is that the healthy osseous walls do not yield. In all 
the cases of so-called dilatation it could be shown that the disease had infected the bone 
thereby impairing its resisting powers- Spongification due to reabsorption of the trabeculae 
seemed to be the principal pathological change. 




MAXILLARY SINUS. 


155 


Differential Diagnosis Between Dental Cysts in the Superior Maxilla and 
Chronic Empyema of the Maxillary Sinus. 

dental cysts. empyema of maxillary sinus. 

Bulging of anterior sinus walls. No bulging. 

Springy consistency of anterior wall with Anterior wall firm and solid, 
parchment-like crackling under pres- 


Fistula into lower edge of canine fossa. 
No trace of pus in middle nasal fossa. 
No nasal polyps. 

General symptoms more often absent. 
Squamous epithelium. 


No fistula. 

Pus present. 

Polyps frequently present. 

General symptoms more often present. 
Cilated epithelium. 


Prognosis and Indications for Treatment . 289a —The prognosis 
for maxillary sinus empyema is good, so far as life is concerned, 
with one rare exception—where cerebral complications occur. The 
prognosis as to cure depends upon many contingencies. 

In the ordinary acute form the disease shows a marked ten¬ 
dency toward self-ablation, even without treatment, either local or 
general. Whether a chronic empyema * will heal under local treat¬ 
ment depends, first, upon whether the exciting cause still persists; 
second, upon the pathological changes which have taken place in the 
sinus. If the original cause still remains, naturally we cannot ex¬ 
pect a cure to result until it is removed. This is particularly 
apropos for a diseased tooth, foreign body, or an occluded ostium. 
The condition which is apt to prove more perplexing is to judge 
the pathological changes which have occurred within the antrum 
and to apply appropriate treatment thereto. Unless threatening 
symptoms prevailed, we would always begin our treatments with 
the needle puncture, followed by copious lavage, at the same time 
seeing that the natural drainage was thoroughly established, re¬ 
moving, if necessary, hypertrophied tissues and bodies to accom¬ 
plish this end. 

After this treatment has been applied for two or three weeks 
with no improvement, the prognosis is certainly not good for a 
cure under this method; although at the commencement of the treat¬ 
ment, taking the usual run of cases for a comparison, the prog¬ 
nosis had been favorable, we now have a different proposition to 


* By chronic empyema it is understood that the disease has lasted and resisted treat¬ 

ment for at least eight weeks. In those cases which have never been treated, this time may 
be lengthened to perhaps twelve weeks, as these will usually behave under treatment pre¬ 
cisely as the acute cases. Hajek has seen numbers of cases in which the disease had lasted 
six months and more, yet have yielded without operative interference. A change m the 
consistency of the secretion is always the first symptom of beginning resolution of the 

SmU 289a. C °Skillern: When shall we Operate in Chronic Maxillary Sinusitis and What Form 
of Operation shall we Choose? Journ. of Laryng., Jan., 191G. 



156 


THE ACCESSORY SINUSES OF THE NOSE. 


deal with, namely, an operation of greater or less severity. What 
can we now promise our patient! This again depends upon our old 
condition of pathological changes. Shall a radical operation be 
advised, or will we operate intranasally in a conservative manner! 
This question cannot be answered in an offhand manner, as every 
case is a law unto itself. All things being considered, the indica¬ 
tion lies with the patient himself. 

Certain individuals are willing to submit to almost any length of treatment in 
order to forego the necessity of an operation. Remembering that cases have been re¬ 
ported cured only after many irrigations, 38 ® a 289,5 we can substitute the Krause 
trocar and cannula for the needle, in the latter the lumen being many times larger and 
more forcible to throw a larger and more forcible stream, thus cleansing the sinus 
of inspissated pus and detritus that would be impossible with the small needle. In 
this manner we can hope to bring about a cure with much more certainty if irriga¬ 
tion is to effect this end. I can vouch for the efficacy of this in a number of cases 
which resist healing under the ordinary Lichtwitz needle 

One can place absolutely no dependence upon the fcetor or consistency of the 
secretion by the first few needle punctures as an indication for the choice of opera¬ 
tion, for I have seen the foulest antrum heal in a few weeks under this mode of treat¬ 
ment. This would seem to be another proof that all foetid maxillary empyemas were 
not of dental origin. 290 

WHEN SHALL WE THEN OPERATE IN CHRONIC MAXILLARY SINUSITIS AND 
WHAT FORM OF OPERATION SHALL WE CHOOSE ! 

In order to properly solve the first problem (when to operate) 
many factors must be taken into consideration. 

(1) The General Condition of the Patient .—If the patient was 
severely affected, unable to follow his usual occupation, suffering 
from continuous or intermittent pain, head suffused and congested, 
sleep badly disturbed, profuse, purulent discharge from nose and 
posteriorly into throat (sudden suppression and stagnation of secre¬ 
tion is even worse), intermittent fever, and generally miserable; 
immediate evacuation by means of the needle puncture should be 
accomplished with strict rest in bed, the application of ice bags to 
the affected side of the face and forehead, in conjunction with a 
brisk calomel and soda purge. This treatment under such circum¬ 
stances would suggest itself, for it at once gives the patient the 
benefit of the doubt, as it in all probability will bring about an 
amelioration of the symptoms, and at the same time put the patient 
in a better condition should an operation subsequently be demanded. 
This can be accomplished in such time as necessity dictates. 

289a. Konig: Cas d’empyeme du sinus maxillaire gueri par vingt sept lavages faits 
a travers le meat inferior. Soci&te de laryng., 30 Juin, 1905. 289b. Koenig: Chronic 
purulent maxillary sinusitis of dental origin. Six months’ daily washing through the 
alveola without result. Twenty-eight washings through the inferior meatus. Laryngo¬ 
scope, p. 640,1911. 290. According to Turner and Lewis (Edinburgh Med. Jour., p. 293,1910), 
the fetor is often due to the interaction of microbes, which in pure culture give off no odor. 



MAXILLARY SINUS. 


15? 


(2) The History of the Disease .—If a patient states that he has 
been troubled for several years with his nose, hut only lately has 
the discharge been profuse and the headaches severe and persistent, 
we can be reasonably certain that it has slowly assumed a chronic 
form, and in all probability will be resistant to ordinary treatment. 
Here, however, all things being considered, an operation in the very 
near future is clearly not indicated. The needle puncture with 
lavage should be instituted and continued daily as long as the 
patient shows any signs of improvement. This will manifest itself 
in the character and appearance of the secretion. If it begins to 
show changes in its character, becomes less foetid, lose its crumbly, 
milky appearance, becomes thicker and does not mix so intimately 
with the irrigating fluid, as well as diminishing in quantity, the 
conservative treatment should be persevered in. It not infre¬ 
quently occurs, however, that under this form of treatment the 
disease becomes checked and reaches a certain stage when the 
patient is relatively comfortable, the discharge being at a minimum 
and the headaches controlled, yet if the time between the treat¬ 
ments is lengthened, an immediate exacerbation of the symptoms 
occurs. In these cases other drugs should be applied to the mucosa 
of the sinus in addition to the normal saline solution of the irrigat¬ 
ing liquid. Nature must be further assisted than is possible with 
mere evacuation of the purulent secretion and cleanliness accom¬ 
plished by the lavage. The lining mucous membrane of the sinus is 
evidently in such a diseased condition that it cannot throw off the 
infection with these means, but requires asepsis and stimulation. 
This can be accomplished with either alcohol or a solution of nitrate 
of silver in varying strengths, irrigating daily with 50 per cent, 
alcohol or 5 per cent, silver nitrate. After the normal saline solution 
has been expelled from the sinus by causing the patient to bend the 
head toward the sound side and forcibly injecting air through 
the needle until no more liquid appears, the syringe is partially 
filled (about two ounces) with 50 per cent, alcohol and the sinus 
slowly filled, the head being held in the upright position until the 
alcohol begins to trickle out of the nose. The needle is then with¬ 
drawn, leaving the alcohol in the sinus. This should be repeated 
after every irrigation until full strength alcohol is used. If the 
disease continues to resist this form of treatment, a solution of 
nitrate of silver may be substituted for the alcohol. The initial 
strength can be 30 grains to the ounce, gradually increasing until 
a 25 per cent, solution (120 grains to the ounce) is applied. It this 
fails to bring about a marked improvement in a very short time 


158 


THE ACCESSORY SINUSES OF THE NOSE. 


(five irrigations), some form of a radical operation must be con¬ 
sidered. At this point let us for a moment consider the advisability 
of using a heavier or more forcible stream of liquid than is possible 
with the ordinary exploring needle. It is, of course, impossible to 
throw a stream with much cleansing strength through an instrument 
with such a small lumen as the needle. On this account, it has 
been argued that the Krause trocar and cannula is much better fitted 
for this work, and possesses decided advantages over the needle on 
account of the comparatively heavy stream made possible by its 
use. It has been my experience that where the needle has failed 
the trocar has also been unavailing, therefore why should one 
submit the patient to the pain always incident to the passage of this 
instrument when the needle puncture can be repeated with little or 
no discomfort? 

Recurrent Attacks. —If, on questioning, it is evident that the 
disease is of long standing, acute exacerbations being frequent, and 
one present at the inception of the present treatment, the indication 
for a radical operation lies largely with the patient himself. He 
knows that conservative treatment will probably bring about an 
amelioration of the symptoms, as it has done many times previously, 
at the same time he is cognizant of the fact that a cure will not be 
obtained, although perhaps hoping that this may actually be his last 
attack. There the surgeon’s duty is clear. He can either institute 
the conservative treatment, promising the patient little in the hope 
of an ultimate cure, or advise a radical operation at once, citing 
otherwise a continuation of the attacks in increasing severity until 
the operation is urgent, running at the same time a certain risk of 
orbital and even cerebral complications, when it will be too late for 
surgical interference to be of avail. The responsibility in any event 
is placed entirely with the patient. 

There is one history which when present, demands an im¬ 
mediate operation, i.e., maxillary sinusitis of dental origin. Antral 
suppuration resulting from the teeth occurs in approximately 20 
per cent, of all cases. It is always extremely chronic, being, in fact, 
chronic from its inception. The pathological process being an ex¬ 
tremely slow one causes a low grade form of inflammation along 
the floor of the sinus, in the alveolar fossa. Even should the offend¬ 
ing root have previously been removed, the disease remains, show¬ 
ing but little tendency toward a spontaneous cure unless good 
drainage has been established. Suppose, however, nothing had 
been done, and certain symptoms pointed toward dental involve¬ 
ment. One or two of the upper (premolar to wisdom) were sensitive 


MAXILLARY SINUS. 


159 


to heat and cold, or percussion with a metal instrument, or seemed 
to feel longer than their immediate fellows. An X-ray film should 
immediately he taken to determine precisely the particular roots 
affected, as well as the extent of the disease. This is particularly 
important, as it must not be forgotten that idiopathic antral dis¬ 
ease may secondarily affect the teeth roots, especially if little or 
no cancellated bone tissue lies between their apices and the floor 
of the antrum. In this way it is often possible to prevent a slightly 
diseased tooth which is amenable to treatment from being need¬ 
lessly sacrificed. If, on the other hand, the film showed us that 
the root was primarily affected, the corresponding tooth must 
immediately be extracted, and the root canal sufficiently enlarged 
with a suitable borer to enable one to irrigate the sinus thoroughly 
and to keep the opening patulous with a well-fitting prothesis made 
by a dentist. Daily irrigation through this opening in the alveolus 
will bring about a cure in almost every* case of antritis of dental 
origin, provided of course that permanent pathological changes 
have not taken place in the mucosa of the sinus. The same form of 
treatment should be instituted in those forms of maxillary sinusitis 
coupled with manifest caries in a tooth where it is possible to com 
nect the two directly by pasing a fine sound through the carious 
portion of the tooth directly into the sinus cavity. The antiquated 
treatment of attempting to favor continuous drainage by the 
installation of a tube in the opening is as uncleanly as it is insuf¬ 
ficient, and should be abandoned. 

(3) The Probable Pathological Condition of the Sinus Mucosa 
and the Osseous Walls .—When this can even approximately be 
determined our indications are much clearer than is otherwise the 
case. If permanent pathological changes in the form of polyps or 
polypoid hypertrophies are present in the antrum, we can irrigate 
until Doomsday with no appreciable effect on the condition. The 
condition of the mucosa can be judged in several ways, (a) By 
the consistency of the secretion. If it remains granular, sinking to 
the bottom of the pus basin, mixing with the irrigating fluid, or 
continuing foetid, we can be assured that such changes have taken 
place in the mucosa as to preclude the possibility of a cure by the 
irrigating route, (b) If the irrigating fluid seems to meet with 
continual resistance at every attempt at lavage it is probable that 
the mucosa is so swollen that the point of the needle becomes therein 
embedded. ( c) When the X-ray shows little diminution in the 
shadow immediately after lavage it is caused by the swollen mucosa 
or polypoid hypertrophies. If either or all of these signs and 


160 


THE ACCESSORY SINUSES OF THE NOSE. 


symptoms are present, some form of radical operation which will 
enable one to thoroughly rid the cavity of these pathological prod¬ 
ucts is unquestionably called for. If the bony walls underlying 
the mucosa show signs of involvement from the 1 diseased mucosa, 
immediately an indication for prompt operative interference is 
given. This manifests itself by tenderness, and in some cases 
cedematous swelling over the antrum. The pain is particularly 
marked at night. The character of the discharge furnishes a clue, 
and osseous disease should be suspected when it remains foetid and 
crumbling, despite frequent irrigations followed by nitrate of 
silver injections. 

(4) Occupation, Social Condition, Age and Sex . General Con¬ 
dition of Patient .—The possession of a chronic purulent maxillary 
sinusitis is of far greater import to individuals following certain 
occupations than to others in different lines of work. Thus a school 
teacher, a barber, a hotel clerk or others in similar employment, 
who constantly come into more or less personal contact with a large 
number of people, find it very much to their disadvantage to be 
continually hawking, expectorating, and blowing the nose, while 
masons, drivers, plumbers, and outside workers in general can 
carry a diseased antrum around with very much less discomfort. 
In these separate occupations it is much more than a personal ques¬ 
tion as to whether they shall be quickly rid of their ailment or 
continue treatment for an indefinite period. In the former a disease 
of this character may mean the loss of their position, while in the 
latter this phase hardly enters into the consideration. It is always 
wise, therefore, in considering the advisability of operating, to first 
bear in mind the particular calling of the individual. The social 
condition of the patient very often gives a decided indication as to 
the present lines of treatment. It is obvious that they who have 
plenty of time and means at their disposal will prove much more 
favorable subjects for conservative treatment than those whose 
time and money are limited. The former are, as a rule, not only 
willing to present themselves at frequent intervals for treatment, 
and to carry out home instructions, but are anxious to avoid any 
form of operation as long as they are made fairly comfortable. 
With the latter this is not always feasible. In the first place, they 
cannot always present themselves at certain times, nor can they 
always give themselves the proper attention, therefore, the oppor¬ 
tunity for a quick permanent cure through operative interference 
offers them a much brighter outlook, even though it entails the loss 
of a few days’ time. Young people who are to be married in the 


MAXILLARY SINUS. 


161 


immediate future must be rid of their complaint at the earliest 
possible moment, therefore an operation is imperative. Age is an 
important factor which must not be overlooked. Any form of a 
purulent maxillary sinusitis in the very young (six months to twelve 
years) which shows a tendency to become chronic should cause 
immediate surgical intervention. In these tender ages the bones 
of the face are very soft and are particularly prone to inflammation 
(osteitis, osteo-myelitis, and periostitis). When the osseous struc¬ 
ture once becomes thoroughly infected the task of a complete cure 
is usually hopeless. Another factor is that the sinuses themselves 
are very small, and the operation is usually not very extensive. 
Some authorities consider all purulent maxillary sinusitis in chil¬ 
dren a true osteo-myelitis. Generally speaking, this is true if the 
disease has progressed any length of time, but it is also true that the 
mucosa of the sinus was probably the primary structure affected, 
and the infection had spread by contiguity to the surrounding 
osseous structures. Scarlet fever furnishes an exception, in that 
the bone appears to be affected simultaneously with the mucosa, 
and the disease runs a most intractable course, being often resistant 
even to the most radical measures. 

In young adults the general system is usually vigorous, and 
will respond quicker to conservative means than in older persons. 
Simple daily lavage in the former, coupled with appropriate vac¬ 
cines, will often accomplish in a week what would require months 
to procure in those of riper age, therefore it is wise to exercise 
patience with these cases, and remember that a cure has been 
accomplishd only after a considerable number of treatments. (In 
one case fifty-nine irrigations.) On the other hand, we must bear 
in mind, particularly in girls and young women, the possibility of 
the disease making such headway that even after a radical opera¬ 
tion the cure is not complete. It is indeed a great handicap for a 
woman to be obliged to carry a chronic catarrh to her dying day, 
even though it incommode only to the extent of the necessity of 
an excessive number of handkerchiefs. 

In the adult, complications in the form of other diseases in con¬ 
junction with the sinusitis are not infrequently encountered, and 
must receive due consideration. Thus, in a case of chronic Bright’s 
disease, or other condition where a general anaesthetic or even a 
surgical shock is contraindicated, any form of a radical operation 
should be approached cautiously. In these cases it is well to care¬ 
fully weigh the subjective symptoms and the drain of the disease 
on the system with the probably immediate deleterious effects of 
11 


162 


THE ACCESSORY SINUSES OF THE NOSE. 


the proposed operation. Local anaesthesia may be an important 
factor in determining this question. In the very aged any form of 
sinusitis is somewhat of a rarity. This is probably due to the con¬ 
tinued reabsorption of the bone causing the antra to become exces¬ 
sively large, and the roominess of the nostrils permitting better 
aeration. When a maxillary sinusitis, however, becomes estab¬ 
lished, it is a question whether they should be subjected to the 
shock of an operation or whether simple expectant treatment is 
advisable. It would seem that even in bad cases, where in a younger 
individual no hesitation in operating would be made, simple drain¬ 
age at the most is as radical a procedure as advisable. These 
patients rarely suffer much pain, and can get along quite comfort¬ 
ably with more or less of a catarrhal discharge from the nose. 
Occasional treatment at home will go far towards minimizing 
this condition. 

Sex .—A young woman with an occupation is in a far dissimilar 
position than a young man occupying even a similar calling. A 
governess or nurse with a chronic discharge from the nose would 
be an object of disgust and suspicion to the rest of the family, while 
in a tutor or coachman it would not be so conspicuous, as men are 
supposed to be subject to more or less catarrh from smoking, etc. 
The female members of a household seem to be particularly im¬ 
pressed with chronic colds or coughs which afflict any of the indi¬ 
viduals who are continually in contact with the children. The fact 
that they are obliged to regularly visit the doctor contributes not 
a little to this dissatisfaction. These facts should be carefully con¬ 
sidered when dealing with such cases, as few employers object to 
an operation with apparent cure, while many would not consider 
keeping an employee around the house that was afflicted with a 
chronic discharge. 

General Condition of Patient .—This may play a very important 
role in deciding the advisability of an operation. If the patient 
shows much anxiety over his condition, being nervous and de¬ 
pressed, bordering on to periods of melancholia, it is wise to con¬ 
sider means for a rapid cure rather than subjecting him to a 
prolonged course of treatment, even though the latter gives 
encouraging signs for an ultimate recovery. The delay may be 
worse for the patient than the suffering which the operation 
entails. I shall never forget the patient of Hajek’s who was so 
impressed by the pus that was washed out of her antrum on 
the first irrigation that she threw herself into the Danube and 
was drowned. 


MAXILLARY SINUS. 


163 


(5) Retention, Threatened Orbital or Cerebral Complications .— 
In symptoms of retention with congestion of face, excessive pain, 
little discharge, and fever despite daily irrigations, some form of 
operation is clearly indicated. Here we are practically certain that 
there is little hope of an amelioration until drainage and aeration is 
established, and delay may only further complications. 

Threatened extension to the orbit makes an immediate operation 
imperative, as these cases once established cause permanent changes 
in the eye, which will follow the individual to the end of his days. 

Cerebral complications from the antrum have been singu¬ 
larly fatal, therefore, it is wise to anticipate such an eventuality, 
and at the slightest suspicion of the appearance of symptoms 
to err if necessary on the safe side by an early and radical 
external operation. 

What Form of Operation Shall We Choosef —This will depend 
upon many exigencies: 

(1) The aetiology of the disease. 

(2) The chronicity of the disease. 

(3) The tendency and course of the disease. 

(4) The age of the patient. 

(5) The social condition of the patient. 

(6) The physical condition of the patient. 

(1) The origin of the disease may furnish decided indications 
for a certain form of operation. If it is of dental origin the diseased 
tooth and root must be sacrificed, and it is better to enlarge the 
bony canal into which the root inserted in order to remove the dis¬ 
eased bone tissue, which had been directly around the apex of the 
root. This procedure is known as the old Cowper method, the 
technique being described on page 177. If the tooth is merely 
drawn and treatment continued with needle puncture lavage, one 
runs the risk of continued infection from the diseased bone in the 
floor of the sinus. That form of operation, which consists in the 
extraction of several teeth and the installation of a large hole into 
the antrum, although still practiced by some general surgeons, 
should be abandoned, as it is as unscientific as it is barbarous. 

(2) The Chronicity of the Disease .—The time given for a sinu¬ 
sitis to become chronic is about four weeks. As a matter of fact, 
this depends largely upon the virulence of the infection, or the 
peculiar susceptibility of the individual. In certain cases the dis¬ 
ease may continue for many weeks, and remain to all intents and 
purposes subacute, i.e., but slight pathological changes have resulted 
in the mucosa, while in others a few weeks’ duration is sufficient to 


164 


THE ACCESSORY SINUSES OF THE NOSE. 


cause changes which are only met with in the most chronic forms. 
The extent of these changes is in direct ratio to the required extent 
of the operation. The greater the changes the greater or more radi¬ 
cal the operation. If a large area of the antral mucosa has under¬ 
gone polypoid degeneration it can hardly be expected that complete 
drainage alone will bring about a cure. Before this can be accom¬ 
plished it will be necessary to thoroughly remove the diseased 
tissue by means of the curette in order that the remainder can 
regenerate, and eventually cover over the defective portions. An 
incision through the canine fossa, so that the parts can be brought 
under immediate inspection, will be the only means to this. end. 
Whether the Caldwell-Luc (p. 190) ortheDenker (p. 196) method is 
chosen will depend upon the fancy of the operator. Both are 
equally effective. The latter is perhaps the easier and the more ex¬ 
tensive, but does not give any better results than the former; at least 
in my hands. There is, however, a slight choice between the two 
under certain circumstances, which will subsequently be considered. 

(3) The Tendency and Course of the Disease .—Let us suppose 
that we had followed out a course of conservative irrigations in a 
male adult until we were convinced that an operation was necessary 
to effect a cure. What form shall we choose? If under our irriga¬ 
tions the disease would abate only to continue in its old course after 
the treatments were suspended, we can take it for granted that 
something a little more pronounced in the aeration and drainage 
will bring about the desired result. Obviously a radical operation 
is not necessary, yet something more than mere cleansing irriga¬ 
tions must be applied. Here the preturbinal method (p. 187) has 
its greatest indication. It can be done under local anaesthesia; little 
tissue is sacrificed; the sinus can be fairly well inspected, particu¬ 
larly by the nasopharyngoscope, topical applications can be made, 
thorough drainage installed, and the patient hardly incapacitated. 
The various operations under the inferior turbinate would probably 
answer in this case, but as they entail sacrifice of more or less 
turbinal tissue they are now practically discarded. If it were sub¬ 
sequently found necessary to reoperate (this has but once occurred 
after the preturbinal in our hands) a considerable portion of the 
radical operation has already been done, and it will only be neces¬ 
sary to resect a portion of the canine fossa wall and curette, the 
nasal opening having already been made. 

(4) The Age of the Patient. —Fortunately, infants and very 
young children are seldom afflicted with purulent sinusitis, due 
mainly to the absence or partial development of the true sinuses. 


MAXILLARY SINUS. 


165 


It must be remembered that in a child one year old, no frontal or 
sphenoidal exists, while the maxillary is about the size of a bean. 
As ethmoiditis almost always complicates maxillary sinusitis in 
children the problem confronts us as to the form of operation indi¬ 
cated. Unless complications (orbital or external rupture) threaten, 
or have supervened, the conservative or intranasal method is on the 
whole better, as the cells can be fairly well exenterated with drain¬ 
age to the antrum and good hope for ultimate recovery. Under a 
general anaesthetic and a good light a small curette is introduced 
beneath the middle turbinate, and all cells from the sphenoid an¬ 
teriorly broken down and removed. After this procedure one finds 
that the indications for an external operation rapidly diminish, par¬ 
ticularly if the patient happens to be a little girl. 

Maxillary sinusitis per se in the young will more frequently re¬ 
quire energetic measures, on account of the extreme softness of 
the surrounding bony structures and their well-known tendency 
towards osteomyelitis. If the nostrils are very small, making intra- 
nasal work both difficult and uncertain, it is better to perform at 
once a modified Denker, with thorough curettage of the entire antral 
cavity. The result will often be a rapid and complete cure where 
temporizing with conservative measures will allow the disease to 
become thoroughly imbedded in the bone, with no ultimate hope 
of a permanent cure. There must, however, always be borne in 
mind the probability of so injuring the secondary tooth germs as to 
prevent their eruption. On this account the operation should be 
approached only as a means of saving life unless an external fistula 
has already formed. 

In the old, extensive radical operations are usually not indi¬ 
cated. . As a rule, a recent case of sinusitis in a patient advanced in 
years is not very severe, due probably to the excessive size of the 
drainage passages. Should it demand something more than con¬ 
servative treatment, an intranasal operation is usually all that is 
required. It is not well to subject one of these patients to an ex¬ 
tensive operation, not only on account of the general surgical shock, 
but also because of the enfeebled recuperative powers of the parts 
themselves. The sensibilities of these old folk are benumbed, and 
the installation of an opening sufficient for drainage is usually more 
acceptable to them than the trouble incident to continued treatment, 
or the discomfort, not to say uncertainty, of a radical operation. 

(5) The Social Condition of the Patient. —A. great deal less can 
be done in the way of a radical operation on a young lady of some 
social standing than, for example, on a maid or waitress, for two 


166 


THE ACCESSORY SINUSES OF THE NOSE. 

reasons. In the first place, in the former if the disease has become 
chronic it is usually of recent date, as immediate attention was 
probably given it, and, secondly, she will have more time to devote 
to subsequent treatment. Most of the female members of the better 
class prefer far to undergo some form of conservative operation 
(when an operation is indicated) than to resort to anything radical, 
even though the after-treatment must necessarily be continued 
over some length of time. I know of nothing which meets these 
requirements so thoroughly as the preturbinal operation. Here a 
conservative operation gives semi-radical results, and at the same 
time is of little immediate inconvenience to the patient. No great 
swelling of the cheek, wound in the mouth, and enforced stay in a 
hospital. For the working class, generally speaking, a Caldwell- 
Luc or Denker is advisable. These patients can nearly always get 
off for a few days for hospital purposes, and after the operation 
little attention is required. 

(6) The Physical Condition of the Patient .—Chronic invalids 
suffering with serious internal disorders (kidney, heart, and liver 
diseases) sometimes acquire antral trouble of operative importance, 
and a serious question arises as to the procedure to be adopted. It 
may be that a general shock would be dangerous, and even the 
discomfort resulting from anaesthesia and hyperaesthesia of the 
teeth, swelling of the cheek, and a wound in the mouth must be 
looked upon with some degree of apprehension. Under these cir¬ 
cumstances we always have a sheet anchor in local anaesthesia. 
When the anaesthetic (novocain 2 per cent.) is properly injected, 
it is astonishing how little pain is experienced, even when the bone 
is being removed. The preturbinal method, for example, is a 
totally different proposition under local anaesthesia than under 
general. The patient does not look upon it with the same degree 
of apprehension, and the post-operative symptoms do not appear to 
be so marked. This is probably due to the less extensive degree 
of traumatism and the greater gentleness exercised with the patient 
in a state of consciousness. The more radical forms of the Caldwell- 
Luc and Denker can also be used under local anaesthesia, with com¬ 
fort to the patient. I recall cases in individuals with pulmonary 
tuberculosis operated upon under this form of anaesthesia with per¬ 
fect results, and no subsequent flaring up of the tubercular process. 

In conclusion, we may say that in the absence of complications 
an absolute indication for the radical operation exists only in those 
cases where complications threaten, the bone is diseased or new 
growths, such as polyps and cysts, are present in the antrum. 



Fig. G8.—Position and bending of sound necessary in attempting to sound the maxillary sinus 










MAXILLARY SINUS. 


167 


TREATMENT. 

Technique of Sounding and Catheterizing the 
Maxillary Sinus. 

Bearing in mind the natural difficulties enumerated above, it is 
at once evident that lack of space is the chief cause of our inability 
to successfully carry out this procedure. To obtain as much room 
as possible and at the same time anaesthetize the parts so that they 
will be insusceptible to the manipulations of the sound, a twenty 
per cent, solution of cocaine with a few drops of 1/1000 adrenalin 
chloride is applied over the middle turbinate, inferior turbinate, 
and septum, and as much of the middle nasal passage as possible. 

After the parts have been contracted and anaesthetized (about 
10 minutes) the nose is washed out with a warm normal salt solu¬ 
tion to clear the nasal pasages of pus and general debris. A 
sound is now bent about one-half inch from the tip in an outward, 
downward and forward direction toward the affected side (Fig! 
68) and introduced beneath the middle turbinate, endeavoring to 
engage the point into the hiatus semilunaris. In the vast majority 
of instances this will absolutely fail. Infraction of the middle tur¬ 
binate (p. 233) may now be tried, but usually with the same result, 
so far as sounding is concerned. The anterior end of the middle 
turbinate must now be removed, and, as the parts are already anaes¬ 
thetized, this may be immediately accomplished. The tip of the 
sound will now readily engage in the hiatus and pull forward until 
the elbow touches on the edge of the processus uncinatus. The 
sound is then again gently pulled forward; often a rocking motion 
is necessary to overcome the hypertrophies which are always pres¬ 
ent in the infundibulum until it slips into the maxillary ostium. We 
can safely say the tip of the sound is through the ostium when the 
curved portion has entirely disappeared behind the projecting lip 
of the processus uncinatus if the sound be bent in the manner de¬ 
scribed. If the introduction of the sound has been successful, a 
slender silver catheter is bent, corresponding to the curve of the 
sound, introduced through the same passages, and the sinus ir¬ 
rigated. The introduction of the catheter, even though it be as 
small as, or even smaller than, the sound, is often more difficult, on 
account of the end engaging with the irregularities of the hiatus. 

Relation of the Ostium to the Internal Wall of the Maxillary 
Sinus .—The normal position varies but little, being situated at the 
juncture of the maxillary and ethmoidal portion of the orbital plate, 
with the lateral nasal wall immediately below and posterior to the 
lachrymal bone; therefore, at the extreme top of the sinus cavity 


168 


THE ACCESSORY SINUSES OF THE NOSE. 


(Fig. 42), the size of the sinus apparently exercises but little influ¬ 
ence on its position. 

The pars membranacea occupies a considerable portion of the 
middle nasal passage and is of surgical importance, because it is 
composed of but two layers of mucous membrane (antral and 
nasal), separating the nasal cavity from the maxillary sinus; there¬ 



fore the thinnest portion of the 
lateral nasal wall. (Fig. 38.) It 
may be bounded above by the 
lamella of the bulla, below by the 
superior margin of the inferior 
turbinate, in front by the anterior 
attachment of processus uncin- 
atus, and behind by the ascending 
ramus of palate bone. It is di¬ 
vided into two parts by the pro¬ 
cessus uncinatus, and is the second 
point of election for exploratory 
puncture of the antrum. (See be¬ 
low.) A number of laryngologists 


Fig. 69.—Position of needle when introduced in prefer this portion of the an- 


relation to inferior turbinate, maxillary sinus and 
nasal septum. 


tral wall for radical procedures 
through the nose. 


Accessory ostia, when present,* are always situated in the pars 
membranacea, either above or posterior (rarely below) the un¬ 
cinate process. (Fig. 49.) They may be either single or multiple 
(the author has seen as many as three), and range from the size 
of a pin head to that of a pea. On account of their favorable posi¬ 
tion for sounding, it should always be ascertained whether one is 
present before any attempt is made to sound the natural ostium. 

The maxillary process of the inferior turbinate forms the thin¬ 
nest osseous portion of the lateral wall of the nose. Thus it is the 
point of election for the needle puncture of the maxillary sinus. 

Technique of Needle Puncture with Lavage . 291 —The anterior 
end of inferior turbinate and especially that portion of the lateral 
nasal wall beneath are painted with a twenty per cent, solution of 
cocaine, the cotton carrier being bent to more easily reach the 
roof of the inferior nasal passage. In ten minutes the parts are 
sufficiently anesthetized. Intro duce a Lichtwitz needle (Fig. 69a), 

* According to Zuckerkandl, in ten per cent, of all cases. 









Fig. 70.—Position of needle in puncture of the maxillary antrum. 


* 










MAXILLARY SINUS. 


169 


working the point beneath the inferior turbinate until it is about 
half way back, then elevate the point by depressing the hand 
until it reaches the attachment of the turbinate with the lateral wall 
of the nose. Press shank of needle firmly against the septum and 
push slowly upward and outward (Fig. 71). A common source of 
failuie is to direct the point of the needle too far downward. 

The needle point should be directed toward the posterior part 
of the eyeball. A sudden penetration with the crackling of bone and 
the fixation of the needle against the septum will show that the pro¬ 
cedure has been successfully accomplished. The needle should 
now be slightly withdrawn to disengage the point from the swollen 



Fig. 69a.— Lichtwitz needle for puncture of the maxillary sinus through the inferior nasal passage. 

mucosa of the opposite side and the end rotated in a small circle 
to ascertain whether the point is freely movable in the sinus. Air 
is now injected into the cavity by means of the syringe. This in¬ 
jection of air may fail for several reasons: 1. There may be a 
spicule of bone caught in the aperture of the needle, in which case 
the stylet should be pushed through while the needle remains in 
place; if this fails to disengage the obstruction, the needle must be 
taken out, cleansed, and again introduced. 2. The needle-point 
may be imbedded in hypertrophied tissue or even a polypoid mass, 
under which circumstances it must be further withdrawn and more 
pressure applied to syringe. When this occurs it is readily recog¬ 
nized by the behavior of the patient when air is first injected. If 
the point of the needle is imbedded in the mucosa, sharp pain is 
immediately felt; if, however, the lumen of the needle is blocked, 
the patient will experience no sensation. 

3. The middle turbinate may be so swollen and the ostium so oc¬ 
cluded with polypoid tissue that the fluid does not easily return. In 
these cases a constant increasing pressure on the syringe usually 
brings the fluid out, often with a decided spurt. 4. The needle may 
have penetrated only the mucous membrane of the lateral nasal wall 
and glided along the bone. This is easily distinguished by the fact 
that the needle is not immovably fixed against the septum, but lies 
freely movable in the nasal cavity. 5. The needle may have pene¬ 
trated both walls of the antrum and appeared beneath the skin of the 
canine fossa. 6. The presence of intra-antral polyps, which by 
valve-like action blocked the ostium from within. 292 

292. Tilley: Some Considerations in the Diagnosis and Treatment, etc. Brit. Med. 
Journ., vol. 2, p. 1370, 1906. 




170 


THE ACCESSORY SINUSES OF THE NOSE. 


Occasionally, even though the needle be properly introduced, it 
is most difficult to push it through the bone, in which case it must 
be re-introduced and the attempt again made on another place. If 
the laryngologist steadies the head of the patient with the opposite 
hand (Fig. 71) the procedure can practically always be accom¬ 
plished, except in those cases where the bone is anomalously thick¬ 
ened, when it will be necessary to use a heavier instrument (Fig. 
72). (The author has never met with such a case in actual prac¬ 
tice.) Exceptional cases have been met 
with in which the bone is so thick and 
dense that it requires considerable 
pressure to force it through into the 
sinus. There is also the danger in these 
cases that when the lateral wall of the 
nose is suddenly penetrated it is impos¬ 
sible to judge the precise moment to 
stop the pressure, and the point of the 
needle penetrated either the anterior 
canine fossa wall or the orbital plate. 
To obviate this it has been our prac¬ 
tice, when difficulty is experienced in the 
first attempts to introduce the needle, 
to place it in position and give it a sharp rap with a fibre mallet. It 
is surprising how quickly this works, and in the many cases in which 
we have tried it the patients are even less disturbed than by means 
of the ordinary method with the hands. It is important to first in- 



Fig. 72.—Antral trocar with cannula. 


ject air into the cavity to make sure the needle is in the maxillary 
sinus. If a liquid was first injected, the needle being in the tissue 
of the canine fossa, an abscess would almost surely result. 

This holds true only when the sinus contains pus. I have seen a number of eases 
in which the needle puncture was made by inexperienced hands and the irrigating 
fluid immediately injected without ascertaining whether the point of the needle lay 
in the sinus. In one case upper and lower eyelids became intensely swollen and dis¬ 
colored, the patient complaining of great pain. Under treatment with ice-cold com¬ 
presses all symptoms disappeared in seventy-two hours, the face resuming its normal 
appearance (see p. 158). In another case the same thing occurred in the canine 
fossa, which also cleared up in a few days. Fortunately in neither case was a maxil- 



Fig. 71. —Position of the hands in 
introducing the Lichtwitz needle into the 
right maxillary sinus. 




MAXILLARY SINUS. 


171 


lary empyema present. Hajek M2a mentions several eases in which this occurred 
with the antrum purulently diseased, which resulted in phlegmonous inflammations 
of the cheek, accompanied by chills, fever, and ankylosis of the jaw, and required 
from eight to fourteen days to heal. 

In empyema of tliis sinus a positive diagnosis can always be 
made by the peculiar bubbling sound emitted when air is injected. 
In chronic cases this is often accompanied by the sudden appear¬ 
ance of a marked foetor. It sometimes occurs, particularly in acute 
cases, that at first the injected liquid returns perfectly clear, giving 
one the impression that the cavity is empty. On continued injec¬ 
tion a large mass of thick pus which does not mix but is agglutinated 
suddenly appears in the solution; therefore it is always wise to 
inject at least several ounces (8-10) before final conclusions are 
reached. 

After finishing the irrigation, it is well to have the patient bend 
the head toward the opposite side while air is forced through the 
needle. In this manner the residual fluid is forced out of the cavity 
by the inrushing air, the ostium, by reason of the head being bent 
over, lying at a low and favorable position for drainage. 

Conservative Treatment.— This form of treatment should al¬ 
ways be tried first (except in cases as enumerated above), as it is 
often astonishing to note how frequently even severe forms of the 
disease recover under a few simple procedures, as the following case 
well demonstrates: 

H. K., male, thirty-eight years old. History of nasal trouble for nearly two 
years. Considerable discharge from the throat, particularly in the morning on aris¬ 
ing. Some discharge of thick mucus and crusts through the right nares. Neuralgic 
headache confined more or less to right side. Complained particularly of inability to 
fix the attention and disinclination to any brain work, complaining of a foul, decaying 
odor in nose, which had been under treatment at various hospitals with little relief. 

Examination: Right nares—mucous membrane hyperaemic, slight hypertrophy 
of middle turbinate, no sign of secretion, although particular attention was paid to 
this point. No objective odor to be noticed. Left nares, normal. Throat—• 
pharyngitis lateralis on right side. On general principles a needle puncture was 
made and on injecting the antiseptic solution a large quantity of crumbly, cheesy 
pus was evacuated which mixed with the water and disseminated a most foetid odor 
over the entire room. The sinus was washed out with about one quart of warm 
sterile normal salt solution, the residue of which was in turn blown out and the pa¬ 
tient told to report the next day. 

The patient presented himself as instructed and the needle was again intro¬ 
duced. This time, while the quantity of pus appearing in the solution was quite 
as large as before, yet it appeared to be what the older surgeons termed “ laudable 
pus,” seeming to be organized, and did not mix with the water, neither was the slightest 
odor appreciable. The patient had also remarked that since the first washing out he 
had not noticed any odor, although he had constantly been on the watch for it. The 


292a. Hajek: Lehrbuch, IY Auflage, S. 112, 1915. 



172 


THE ACCESSORY SINUSES OF THE NOSE. 


next irrigation brought a large mass of jelly-like mucus, but no pus. The fourth 
and last lavage occurred a week later and the solution returned perfectly clear. The 
patient was discharged with instructions to return immediately should the slightest 
suspicion of trouble manifest itself, but up to the present writing, although now 
over two years, he has not put in a reappearance. 

The forms of conservative treatment are as follows, in order of 
their severity: (1) irrigation through the natural ostium or, when 
present, the accessory ostium; (2) needle puncture through the 
middle nasal passage; (3) needle puncture through the inferior 
nasal passage; (4) introducing trocar through inferior nasal pas¬ 
sage (Krause method); (5) boring through the alveolus after ex¬ 
traction of a tooth (first molar or second premolar) (Cooper 
method) (semi-radical treatment); (6) creating a large opening in 
the middle nasal passage (Onodi method); (7) creating a large 
opening in the inferior nasal passage (Mikulicz-Krause method); 

(8) various modifications of No. 6 and No. 7 (Dahmer method); 

(9) Canfield’s method; (10) pre-turbinal method with preservation 
of the inferior turbinate. 

1. Washing out through the natural ostium is a procedure which 
can be accomplished but rarely, on account of the anatomical con¬ 
figuration of the parts. When, however, the middle turbinate hangs 
at some distance from the lateral nasal wall, other conditions being 
favorable, it can sometimes be accomplished after applying a ten 
per cent, cocaine solution with 1/2000 adrenalin chloride to shrink 
as well as anaesthetize the surrounding parts. 

A probe suitably bent should first be introduced to ascertain the 
proper angle which the cannula must be curved. Introduction 
should then be accomplished as has already been described (see 
technique of sounding), the nozzle fitted to the cannula, and gentle 
pressure on the syringe applied until free return of the liquid 
occurs. 

There are two drawbacks to this method: 

a. The mucous membrane of the ostium is often so swollen that 
the introduction of the cannula closes the lumen to such an extent 
that the injected solution only returns with difficulty; therefore, 
inspissated pus or cheesy clots can not possibly escape, and the 
lavage only partially accomplishes its purpose. 

b. Often when the earlier introductions of the cannula have 
been accomplished with little difficulty, the mucous membrane, after 
several catheterizations, reacts from the constant irritation pro¬ 
duced by the introduction, with consequent tenderness and swell- 


MAXILLARY SINUS. 


173 


ing, making subsequent attempts at washing out more and more 
difficult and finally abortive. 

2. Needle puncture through the middle meatus is a method em¬ 
ployed by a few specialists, notably of the Killian school of Ger¬ 
man laryngologists.^ 93 It has the advantage of penetrating the 
thinnest portion of the lateral nasal wall, namely, the pars mem- 
branacea. The danger of this procedure is injury to the orbit 
from the point of the needle (see Figs. 57, 58), but this has been 
done away with by Fletcher 294 by using a curved needle (Fig. 73), 
which is hooked through the pars membranacea, thereby working 
from behind forward and away from the orbital contents. 

In contradistinction to these unfortunate results, the following- incident which 
occurred in the hands of one of my associates shows how tolerant, under certain, cir¬ 
cumstances, the orbital tissue may be to great traumatic insult: 

T. E., twenty-one years. Female. Needle puncture made into left maxillary 
sinus. Air was successfully forced in, which proved the opening at the end of the 
instrument was in the sinus cavity. The needle was then advanced a few millimetres 
(a false move) and normal salt solution injected, which was immediately withdrawn, 
but not before two ounces of the solution had been introduced. At once it was noted 
that the soft tissues both above and below the eyeball were becoming enormously dis¬ 
tended, so that in a few moments the eye became tightly closed and the left cheek 
tense, discolored, and greatly swollen. The condition was one sufficient to cause con¬ 
siderable alarm for every one concerned. Cold compresses were instantly applied, 
which after a few moments relieved the tension. A sedative lotion was prescribed 
and the patient sent home. The following day she appeared at the hospital, the con¬ 
dition being decidedly improved. At the end of four days all signs of the accident 
had disappeared. 

It so happened in this case that no disease existed in the maxillary sinus, other¬ 
wise infection, with the formation of an orbital abscess, with probable loss of the 
eye, must certainly have followed. 

Occasionally one experiences difficulties in forcing the point of 
the needle through the lateral nasal wall, as it is impossible to ob¬ 
tain much leverage for this purpose. This method may be held as an 
alternate for the puncture beneath the inferior turbinate and ap¬ 
plied only when, for any reason, it is inadvisable to use the latter. 

Serious Complications Following Needle Puncture. 

Certain authorities have experienced unpleasant consequences following this 
procedure. 295 - 295b Butt * experienced a very severe hemorrhage in a robust woman 
of sixty-four years of age which continued for three hours, despite a postnasal plug 
with packing of the nose. It was finally controlled by packing beneath the inferior 

293. Killian; Die Probepunktion der Nasennebenhohlen. Verh. d. Ver. Suddeutsch. 
Lary., S. 93, 1896. 294. See Reiner’s Catalogue, Wien. 1908, p. 98. 295. Hajek: Ueble 
Zufalle bei der Kieferhohlenpunktion. Verh. deutsch. Laryng. Gesellsch., S. 163, 1907. 
295a. Kronenberg: Ueber iible Zufalle bei der anborung der Oberkieferhohle und deren 
Verhutung. Zeitschr. f. Larvng., Bd. 4, S. 285, 1911. 295b. Culbert: Report of a Case 
of Chronic Suppuration of the Antrum of Highmore. Puncture Followed by Septic Pem¬ 
phigus and Death. Laryngoscope, p. 824, 1910. 

* W. R. Butt. Personal communication. 




174 


THE ACCESSORY SINUSES OF THE NOSE. 


turbinate. This cause of hemorrhage was undoubtedly due to laceration of the 
mucosa on the lateral nasal wall, the point of the needle having slipped before it 
penetrated the bone. 

Bowen 295c reported two cases of air embolism with one death, Claus 295d two 
deaths from heart-failure, and Halle 295e one death from sepsis. 

Air embolus when present causes the most alarming and 
dangerous symptoms 2956 and may have a fatal termination, several 
cases having been reported. 2956 ’ 295 * 1 ’ 29511 It is probable that in the 
fatal cases the embolus lodged in the brain near the respiratory 
centre as death was due to depression of respiration. Two positive 
cases have been reported 2956 ’ 295 * 1 in which the air embolus was 
found in the pulmonary artery and heart on autopsy. Air 
emboli in brain or cord are difficult to substantiate by post 
mortem examination. 

The only apparent way by which air can enter the right heart 
would be through the possibility of the needle entering the lumen 
of a vein in the antral mucosa. 




Fig. 73.—Fletcher’s needle for puncture of the maxillary sinus through the middle na3al passage. 


Gording 295h in experiments with needle puncture found that the point 
of the needle not infrequently elevated the mucosa so that when the air or 
irrigating fluid was injected a considerable portion of the membrane was loosened 
from its attachment to the underlying bone. I do not entirely agree with 
Boenninghaus 295f when he states that this air under the membrane of the inner 
wall probably can only give rise to an emphysema but not an embolus in a vein. 

In all the fatal cases the symptoms showed sudden collapse 
immediately following the injection of air and that considerable 
pressure was used as the injected air from the syringe met with 
considerable resistance. 295 * 

Blindness from an air embolus has been reported by Hirsch. 295 * 

Needle puncture of the right maxillary sinus which on injection of air was 
followed by immediate blindness in right eye. An eye ground examination was 
made within one minute. The arteries appeared as gleaming white bands. Blood 
began to appear gradually in the peripheral arteries and after two or three minutes 
returned to normal. 

? owen * T Wo Cases of Air Embolus Following: Exploratory Puncture of the An- 
trum of Highmore. Ann. Otol., Rhin. and Lary., p. 180, 1913. 295d. Claus: Vier lible 

Zufalle, darunter zwei mit todlichern Ausganee, bei der punktion der Oberkieferhohle. Beitr. 
z. Anat., Phys., Path. u. Ther. d. Ohres. d. Nase u. d. Halses, Bd. 4, A. 88, 1911. 295e. 
Halle: Diskussion. Zeit. f. Laryng., Bd. 4, S. 801, 1912. 295f. Boenninghaus: Ueber die 
Luftembolie bei Kieferhohlen punktion. Arch. f. Laryng., Bd. 33, S. 318,1920. 295g. Hirsoh: 
Luftembohe der Artena Centralis Retinae in folge ausspuling der Kieferhohle Klin. Mona- 
tsbl. f. Augenhk., S. 348, 1920. 







MAXILLARY SINUS. 


17 5 


In analyzing these cases, it would appear the point of the 
needle raised the antral mucosa from the underlying bone so that 
air was injected into this newly formed space. This assumption 
is borne out by Gording’s experiments upon rabbits in which this 
occurred. 29511 To avoid these complications, exercise great care 
whenever resistance is offered to the air about to be injected and 
under no circumstances attempt to force it through. Partially 
withdrawing the needle and seeking the proper lumen of the sinus 
will usually suffice to bring about the free escape of the air. 
In an experience of over fifteen years of extensive puncturing, 
I have never seen one case that has given me one moment’s 
anxiety which is to be attributed to the care shown in making 
the injection. 

3. The needle puncture through the inferior nasal passage 
offers the safest, surest, and easiest method of ascertaining the 
contents of the maxillary sinus. It can be accomplished almost 
without pain, and after sufficient cocainization requires but a 
moment to introduce the needle. Immediately after a positive 
diagnosis by needle puncture is established it is always indicated, 
before commencing active treatment, to ascertain, the cause of the 
maxillary sinusitis, as frequently this will entirely change our mode 
of treatment. The upper teeth of the affected side should be 
examined by tapping to see whether they are abnormally sensitive. 

Cavities between the teeth should be sought for, and old crowns 
on the affected side are to be viewed with suspicion. It must be 
remembered that the teeth are only the starting point of a dental 
empyema, and the real cause lies in the ostitis of the bone between 
the roots and the antrum floor. It is indeed rare to find a direct 
communication between a tooth cavity and the maxillary sinus 
without periostitis around the socket. 

The frontal and ethmoidal sinuses on that side must also be 
examined, as it is possible that the maxillary sinus is acquiring 
some or all of its pus from these sinuses. Naturally, if either 
of these possibilities were the case, the form of treatment would 
be influenced accordingly; ix., when the root of a tooth caused the 
empyema, the treatment through the alveolus after the tooth or 
root has been drawn should be instituted. If any one of these 
forms of treatment has been decided upon, what solution shall we 

295h. Gording: Serious Complications in the Puncture of the Maxillary Antrum. Ann. 
Otol., Rhin. and Laryng., p. 293, June, 1920. 





176 


THE ACCESSORY SINUSES OF THE NOSE. 


use and how often shall the treatment be applied? Sterilized 
warm normal salt solution seems to be the best medication to use, 
especially for the first few days, the cavity being irrigated daily 
with at least one quart. Continue this daily for perhaps one week, 
then every other day, and, finally, semi-weekly, until cured. 

How long should we continue to use the normal salt solution be¬ 
fore changing the treatment ? That depends entirely upon the con¬ 
dition of the secretion.* If the primary character of the pus is 
crumbly, cheesy, foetid, and mixed with the injected solution, form¬ 
ing a milky mass, which at the end of one week had not changed in 
character or quantity, a change of treatment is clearly indicated. 
This change should consist either in the addition of some antiseptic 
(carbolic acid) or counterirritant (iodine) to the solution (5 per 
cent, carbolic acid is about as strong as is safe, and iodine 10 per 
cent.); both substances, after several applications will cause more 
or less reaction. A better plan is to use alcohol in varying 
strengths, as follows. After irrigation the remaining liquid is re¬ 
moved from the sinus by the forcible injection of air. A 50 per cent, 
solution of alcohol is now very slowly injected through the needle 
until the antrum is filled, which is determined by the appearance of 
the alcohol in the nose. The patient throws the head backward and 
toward the affected side, and holds it in this position for two or 
three minutes, when the alcohol is allowed to escape. This treat¬ 
ment should be continued after each lavage, gradually increasing the 
strength of the alcohol until it reaches its full 95 per cent. 

If this does not bring about a full cure, the substitution of 
nitrate of silver in increasing strengths (from gr. xxx-oz. i to 3ii- 
oz. i) for the alcohol should be tried before applying more radical 
measures. If after a few irrigations with these medicaments, the 
purulent material shows no change either in quantity, quality, or 
consistency, one of the following methods must be resorted to. 

At this point I should like to call attention to those forms of frontal-ethmoidal 
sinusitis which Lermoyez 296 describes as following lavage of the maxillary sinus. He 
attributes the case to the fact that purulent material being forced out of the ostium 
some naturally finds its way into the ethmoidal and frontal ostiums, thereby setting 
up an acquired sinusitis in these cavities. 

This point, to my mind, is not well taken, because: 1. It is well known how the 
maxillary sinus may act as a reservoir to the frontal remaining filled with purulent 
material for months without reaction and then cleared by a single irrigation, demon- 

*If on succeeding injections, the fluid seems to meet with some obstruction in the sinus, 

it is likely that polypoid degeneration of the mucosa or polyps are present in the cavity, 
The point of the needle becomes imbedded in this mass, causing the fluid to emerge from 
the lumen only with difficulty. 

296. Lermoyez: Indications et Resultats du Traitement des Sinusitis max. et Frontales. 
Annales des mal. de l'Orielle, etc., Nov., 1902. 



MAXILLARY SINUS. 


177 


strating that no infection of the mucous membrane had taken place. 2. The experi¬ 
ments of Mendel 297 have demonstrated that it is impossible to force liquid from the 
antrum into the frontal sinus via the infundibulum. My own experience tends to 
show that while a certain number of patients complain of a dull pain extending 
over the frontal and maxillary sinuses of the affected side for some hours after 
lavage, nevertheless this pain always disappears over night. This would seem to 
show that the pain was neuralgic and incidental to the mechanical irritation of the 
lavage and not to any infection. 

4. Introducing a trocar through the inferior nasal passage: 
This procedure is similar to the needle puncture, except a larger 
instrument is used, thereby permitting a heavier and more forcible 
stream to be thrown into the sinus, as well as allowing the insuffla¬ 
tion of powder through the cannula. 

Technic: Cocainize as in ordinary needle puncture, adding a 
few drops of adrenalin chloride to the cocaine solution. Introduce 
the point of the trocar under the middle of the inferior turbinate 
and endeavor to penetrate the antral wall. 

Frequently this is found to be impossible on account of the inferior turbinate 
preventing the point of the trocar from reaching the thin portion of the lateral wall. 
Under these circumstances it will be necessary to either luxate the turbinate toward 
the septum or to resect the anterior portion in order to acquire room. Either of these 
procedures requires but a moment’s time to perform, so will hardly cause delay. 

Now the point of the trocar will easily penetrate into the 
antrum. After the cavity has been thoroughly lavaged with a’ 
quart or more of warm saline solution, all excess of fluid is expelled 
by forcible insufflation of air, with the head inclined toward the 
opposite side. 

After the cavity is made as dry as possible, the mucosa is 
covered with a suitable antiseptic powder and the cannula with¬ 
drawn. This treatment should be continued daily until a decided 
change takes place in the character of the secretion, after which 
it may gradually be discontinued until entire recovery occurs. 

If subsequent introductions of the cannula are attended with a certain amount of 
difficulty on account of inability to find the original puncture, it is -wise to make a 
mark on the cannula showing the depth of the puncture from the entrance of 
the nares. 

Suppose we had continued this treatment for' several weeks 
with no more improvement than was originally shown at its incep¬ 
tion, what course must we take in order to obtain more permanent 
results? The answer would naturally be, something more radical 
must be done. However, before any other form of operation is 
decided upon we must determine absolutely whether there exists, 
directly or indirectly, any dental complication; in other words, 
whether any of the teeth on the affected side which are in relation 


297. Menzel: Experimentelle Kieferhohlenspiilungen. Arch. f. Lary., Bd. 17, S. 371,1905. 



178 


THE ACCESSORY SINUSES OF THE NOSE. 


to the antral floor are affected. The importance of this cannot be 
over estimated, for it might prove a source of no little embarrass¬ 
ment to operate intranasaliy and find subsequently that a diseased 
root was prolonging the affection. If any dental symptoms can be 
elicited, the patient should be referred to a dentist skilled in these 
matters, and at the same time have an X-ray picture taken. 

If such is found to have been the case and the cause 
removed, our irrigations will probably bring about a 
favorable ending. If, on the other hand, nothing points 
toward any dental complication, our choice lies between 
the intranasal method (pre-turbinal) or the radical 
operation through the canine fossa. 

5. Boring through the alveolus after excavation of 
a tooth (Cowper method) * : This method is not to be ap¬ 
plied unless a carious tooth or root is causing the empy¬ 
ema. After extraction of the offending tooth (usually 
the second premolar or the first molar), a pledget of 
cotton saturated with a 20 per cent, solution of cocaine 
Gu'a'rdVd * s firml y P acke d in the cavity for ten minutes. A large 
bo a e^ mann dental drill or a guarded Hartmann borer (Fig. 74) is 
now used to make an opening into the sinus. 

This is often reported to be a painless procedure because the bone is free from 
nerve endings. While this is true, nevertheless the lining of mucous membrane of the 
sinus is usually swollen and exquisitely tender so that when the sharp point of the 
instrument commences to penetrate into the cavity the pain is often considerable. As 
the mucous membrane of the sinus has not been anaesthetized by the first applica¬ 
tion, it is well at this point to withdraw the instrument and make a fresh application 
of cocaine directly in the sinus cavity after applying cocaine through the hole by a 
cotton pledget wrapped very tightly upon the applicator. 

The opening is now enlarged either by a curette (somewhat 
difficult) or, better, by reaming out the opening with the borer. 
This is accomplished by introducing as in the first instance, then 
pulling the handle slightly at right angles and revolving so that 
the ridges cut the walls in an oblique manner. (Fig. 75.) When 
the opening is sufficiently enlarged, the cavity is washed out with 
normal salt solution, powder insufflated, and the obturator inserted. 

This obturator or plug should have been already made by the dentist, consisting 
of a medium soft rubber peg held together by two bands, which fit around the two 
neighboring teeth. Hollow tubes are hardly to be recommended, as they not only 
become occluded by granulation tissue and secretion, but also allow the passage of 
particles of food into the sinus, causing re-infection and prolonging the course 
of the disease. (Fig. 76.) 

This operation was really performed nearly a century before Cowper’s time bv 

Meibom (1650). J 





MAXILLARY SINUS. 


179 


Instruct the patient to syringe out the sinus morning and 
evening with the salt solution, reporting from time to time for 
control treatment. He should also be cautioned to allow the cavity 
to thoroughly drain (which they 
often themselves facilitate by suck¬ 
ing it out) before reinserting the 
plug, but not to permit it to remain 
out for too long a time, as it is sur¬ 
prising how quickly granulations 
form at this place, making its 
replacement difficult and often im¬ 
possible. After healing is estab¬ 
lished the plug is permanently 
removed and closure of the wound 
occurs in a few hours. 

6. Creating a large opening in 
the middle nasal passage : 298 - 300 
This method consists in perforating 
the pars membranacea of the lateral 
nasal wall and enlarging the opening 
as much as possible in all directions. 

Onodi 300 has constructed a dilating 
trocar which appears to be particularly adapted to this work. 

Method: The entire procedure is very simple. After cocain- 
ization of the middle nasal passage the trocar is introduced 
directly below the centre of the middle turbinate and, after being 

A sprung apart, is withdrawn, leaving a long lacera¬ 
tion in the pars membranacea. The loose and 
hanging fragments of bone and mucosa are 
removed with the forceps, and the operation is 
finished. 

In spite of the simplicity with which this pro- 
for closing opening in cedure is carried out, the disadvantages are many: 



Fig. 75. —Enlarging the opening in the 
Cowper operation through the aveolar process 
by reaming out the sides with the burr. 


the alveolus after the 
Cowper operation. 


(1) The opening is at the highest point of the 


antral cavity. 

(2) There is danger of wounding the orbit. 

(3) The middle turbinate often must be resected. 

(4) Granulations form quickly around the wound, thus making 

subsequent manipulations very painful. _ 

298. Rethi: Die Behandlung der Nebenhohleneiterungen der Nase. Wien. med. 
presse., Bd. 37, S. 536, 575, 1896. 299. Siebenmann: Die Behandl. der chron. Eiter der 

Highmorshohle durch Resektion der oberen Halfte ihrer nasalen Wand. veTh. d. sfidd. 
Lary., S. 342, 1899. 300. Onodi: Die Eroffnung der Kieferhohle lm raittleren Nasengange. 
Arch. f. Lary., Bd. 14, S. 154, 1993. 






180 


THE ACCESSORY SINUSES OF THE NOSE. 


7. Creating a large opening in the inferior nasal passage 
(Krause, 301 Mikulicz 302 ).* Method: The anterior half of the in¬ 
ferior turbinate, middle and inferior nasal passages are anaesthe¬ 
tized with 20 per cent, solution of cocaine until tactile sensi¬ 
bility is absolutely destroyed. Equal parts of adrenalin 1/1000 
and of cocaine 20 per cent, are applied several times to 
control hemorrhage. 

Many authors are now opposed to the use of adrenalin on the ground that 
the tendency to secondary hemorrhage is greatly augmented by its use, due to the 
vascular relaxation which always follows from two to ten hours after the opera¬ 
tion. The author, however, is of the opinion that the enormous advantage derived 
from the almost bloodless operating field more than compensates for any tendency 
toward secondary hemorrhage, which in any case is readily controlled by a 
fresh tamponade. 

A suitable pair of nasal scissors is used at this stage to sever 
the anterior third of the inferior turbinate, which should be done 
as close to the lateral nasal wall as possible. Some difficulty will 
often be encountered in this step where the turbinate lies close 
to the external wall. Bleeding is controlled as much as possible 
with adrenalin. 

Now the free end of the turbinate is removed, preferably 
with a snare. Needle puncture is made, which at this particular 
stage of the operation is of great service for two reasons: (1) it 
orientates the operator as to the precise position of the maxillary 
process; (2) it irrigates and cleanses the operating field. 

The needle is allowed to remain, acting as a director for the 
point of the instrument used to open up the sinus, the best instru¬ 
ment for this purpose being that of Welhelmenski (Fig. 77.) 
After the point has been floored through the wall below the 
inferior turbinate the instrument is withdrawn, pulling strongly 
forward to engage as much of the bony partition as possible 
which draws the splinters of bone outward into the nasal passage. 
An antrum punch is now introduced and the opening enlarged 
forward and backward until the forceps cease to engage the wall. 

*The so-called Krause-Mikulicz operation does not really represent the original pro¬ 
cedure as carried out by these operations. Mikulicz, working in the dark, used a right-angle 
stylet to open the antrum through the inferior nasal passage, and Krause merely modified 
the instrument into his well-known trocar and cannula for the same purpose. Lothrop, of 
Boston, 3 03 however, was the first to publish complete reports of this method of operating, 
and to him naturally belong the honors of being the discoverer. A refinement of this oper¬ 
ation which presents somewhat greater technical difficulties but more than compensates for 
one’s pains by the brilliant results obtained is offered by a procedure recently suggested by 
Dahmer. (See page 183.) 

301. Friedlander: Zur Therapie des Empyema Antra Highmori. Berl. klin. Woch., 
Bd. 26, S. 815, 1889. 302. Mikulicz: Zur Operation Behandlung des Empyems der High- 
morshhole. Arch. f. klin. Chirurgie., Bd. 34, S. 626, 1886. 303. Lothrop: Empyema of 
the Antrum of Highmore. A New Operation for the Cure of Obstinate Cases. Boston Med. 
and Surg. Journ., vol. 136, p. 455, 1897. 



MAXILLARY SINUS, 


181 


The posterior edges of the opening can be enlarged also with 
the Grunwald of any straight bone forceps. After the open¬ 
ing has been made as large as necessary the antrum and nose are 
packed with selvaged iodoform gauze. 


Various medicated gauzes have been recommended as a substitute for 
iodoform gauze as a dressing after the operation, but is questionable 
whether they answer the purpose as well as the latter, certainly not as far 
as the author is concerned. 


If the anesthetization has been sufficiently intense, the 
operation can usually be carried out with but a slight amount 
of discomfort to the patient. The most painful step is when 
the posterior edge of the opening near the insertion of the 
turbinate is being enlarged. This is, of course, due to the 
nerve-trunk lying in this position. (Plate I.) 

After-treatment .—As the packing of the sinus and nose 
will cause intense discomfort, if not actual suffering, it is 
wise to administer either a hypodermic of morphine or a 
30-grain sulphonal powder at bed-time on the day of opera¬ 
tion. The patient should observe the rules laid down follow¬ 
ing an operation. The packing is removed on the third day, 
slowly and gently, using a large quantity of peroxide and 
warm water to loosen dried blood and secretion, so as to pre- fig. 77 .— 
vent hemorrhage, which would greatly interfere with treat- e a n n s t k r ^f 
ment. The patient is always relieved by this procedure. trocar - 
Either of the following methods of treatment may be used: 
(1) Wet method: Cleanse thoroughly the antrum by means of a 
suitable syringe with a curved nozzle and warm normal 
salt solution until returning fluid is free from pus. Cause the 
patient to bend the head toward the sound side to facilitate the 
escape of liquid from the sinus. Pack the cavity moderately full 
with iodoform gauze strips in such a manner that the floor of the 



sinus is well covered, not allowing any gauze to protrude into the 
nasal cavity that would interfere with the passage of air through 
the nose. The dressing should be changed daily so long as any 
foul odor persists or the secretion of the pus is copious. When 
the discharge begins to show distinct diminution, apply the dressing 
every other day, gradually increasing the intervals of packing 
until the mucous membrane no longer secretes. 

(2) Dry method: After the first packing is removed, the maxil¬ 
lary sinus is thoroughly wiped out by means of absorbent cotton 
wound around a cotton carrier and suitably bent to allow easy 
introduction through the wound into the antrum. Care must be 







182 


THE ACCESSORY SINUSES OF THE NOSE. 


taken to see that the cotton is secure, otherwise it may readily 
become fastened to a spicule of bone and, on withdrawing the probe, 
remain in the sinus, thus continuing the suppuration. The mucous 
membrane on the floor of the sinus should be made as dry as possi¬ 
ble. Iodoform or any suitable antiseptic dusting powder 304 is now 
blown into the cavity until the floor and wall are covered, no more 
packing being introduced. Continued treatment every day or second 
day until pathological secretion from sinus has been checked. 

(3) Combination.method: Same as the dry method, with the 
exception that the patient is taught to wash out the sinus between 
treatments, with a suitable syringe. This should be done, at first, 
night and morning, gradually diminishing the lavages in ratio to 
the formation of the secretion. 

If the time of healing appears to be protracted, it may be acceler¬ 
ated by the instillations of about two drachms of 95 per cent, alco¬ 
hol at the end of each treatment. This acts as a powerful detergent 
upon the polypoid masses in the mucosa and, relieving the lining 
membrane of its excess of fluid, tends to hasten regeneration. 

The dry method of treatment is indicated in neurotic and sensi¬ 
tive individuals in w r hom the removal and application of the packing 
are a constant source of dread. It is also applicable to those 
patients who, for one cause or another, find it impossible to present 
themselves regularly for treatment. 

Advantages of this method: (1) Operation can be done most 
satisfactorily under local anaesthesia, and the patient is not neces¬ 
sarily incapacitated from his work. 

(2) The opening is so situated that interior and certain parts of 
lining membrane can be examined with nasopharyngoscope. 

(3) Opening is in the lowest portion of the sinuses that it is 
possible to obtain through the nose; therefore, moderately good 
drainage is established. 

(4) If a radical operation is subsequently found to be neces¬ 
sary, an important and difficult step in the operation will have 
already been performed (opening into the nose). 

Disadvantages: (1) Only the merest glimpse into the sinus 
cavity can be obtained without the aid of special instruments; 
therefore, the actual pathological condition of the mucous mem¬ 
brane must be largely surmised. 

(2) The opening shows a great tendency to contraction by gran¬ 
ulation before healing has been fully established. 

(3) After-treatment always more or less painful. Regarding 

304 ] Menge: Clinical Notes on the Action of a New Iodine Preparation in Nose and 
Throat Work. Laryngoscope, p. 491, 1907. 





Fia. 79.—Freeman’s 
syringe. 






































MAXILLARY SINUS. 


183 


the dryness of the nares following this operation, it has been our 
experience never to have seen this complained of in a single case, 
although sought for. This can possibly be explained by the fact 
that only a small portion of the inferior turbinate was resected 
(probably one-fifth), merely sufficient to allow one room to intro¬ 
duce the trocar. 

(4) The resected end of the anterior turbinate often exhibits a 
marked tendency to hypertrophy and obstruct the nasal passage, 
thereby making it necessary to perform a secondary resection. If 
too much of the turbinate is removed, a perma- /p 

nent dryness of the nose on that side will follow. 

Hirscli 304a has endeavored to obviate this disadvantage 
by temporarily resecting the inferior turbinate and infract- WV 

ing it toward the nasal septum while the operation was 
being performed. At its conclusion the turbinate was again PjRJ 

brought into place and held in position by gauze packing. 

This operation, however, does not seem to have met with |JJS 

general favor. ^*5^. Flfd 

8. Numerous modifications of the Krause- i JGX Ml J 
Mikulicz operation have from time to time been 
advanced, all aiming at some advantageous pur- 
pose. One of the best of these, and one which 
has proved of considerable worth in the hands of Flo . 80 ._^ a subpel . 
the author, is that suggested by Dahmer. !£ 8ynnge forlocal aneea - 

Dahmer’s Method : 305 The purpose of this method is to create 
a large opening beneath the inferior turbinate and turn a flap of 
mucosa from the nose into the antrum along the floor, thus prevent- 
ing granulations springing up from the edges and insuring a per¬ 
manent patulous communication between the nose and maxillary 
sinus. 

Method: (1) Prepare the nose by irrigation and application of 
the 20 per cent, cocaine-adrenalin solution on the lateral nasal wall 
above and below the inferior turbinate and corresponding portion 
of nasal septum. 

(2) Inject subperiosteally 1-3 syringefuls (2.0-6.0 Cc.) of a 
1 per cent, novocaine-adrenalin solution directly in front of 
the anterior attachment of the inferior turbinate and in the infe¬ 
rior nasal passage. (Figs. 80, 81.) Wait fifteen minutes. 

(3) Irrigate antrum by means of the needle puncture. 


304 a . Hirsch: Die Behandlung des chron. Kieferhohlenempyema, etc. Monat. f. 
Ohrenhk., S. 637, 1911. 305. Dahmer: Die breite Eroffnung der Oberkieferhohle vonder 
Nase aus mit Schleimhautplastik und persistierender Oeffnung. Arch. f. Lary., Bd. 21 S. 




184 


THE ACCESSORY SINUSES OF THE NOSE. 


(4) Introduce the nasal scissors above and below the inferior 
turbinate, and, keeping close to the lateral wall, cut through the 
anterior third. (Fig. 82.) 

(5) Introduce the snare into the incision made by the scissors 



Fia. 81.—Dahmer’s method. 1st step. Injection in front of and beneath anterior end 
of inferior turbinate. 

and after pressing back the shank as far as possible remove the 
detached portion of turbinate. (Fig. 83.) 

(6) After thorough sponging with adrenalin 1/1000, a right- 
angle knife (Fig. 84) is used and the mucosa incised in three direc- 



Fig. 84.—Right-angle knife. 


tions, making a flap which has for its attachment and base the 
floor of the nose. (Fig. 85.) 

(7) The flap is now submucously resected with a small sharp 
elevator down to the middle of the floor of the nose and turned 
back against the septum. This is the most difficult step in the 
entire procedure, and the result of the operation depends largely 
upon its successful accomplishment. 

(8) A Welhelmenski trocar is introduced in the posterior- 
superior angle of the wound and pushed into the antrum, and on 






w > 


Fig. 82.—Dahmer’s method. 2d step. Cutting 
the anterior third of the inferior turbinate close to the 
lateral nasal wall. 



83.—Dahmer’s method. 3d step. Remov¬ 
ing the incised portion of the inferior turbinate 
with the snare. 



Fig. 85.—Dahmer’s method. 4th step. Making 
the flap of mucosa with the right-angle knife, leaving 
the base toward the nasal floor. 


Fig. 86.—Dahmer’s method. 5th step. Intro¬ 
ducing the Welhelmenski trocar and penetrating the 
antrum at the superior posterior angle of the wound. 






Fig. 87. —Dahmer’s method. 6th step. Using 
the Wagener punch to bite forward and complete the 
opening into the antrum. 



Fig. 88. —Dahmer’s method. 7th step. The 
operation completed, showing the flap of mucosa 
turned into the antrum. 



Fig. 88a. —Initial incision along lateral wall of 
piriform opening. Dotted line shows line of incision 
of mucous membrane flap to be made later. Note 
that the dotted line passes through the mucous 
membrane of the lateral wall of the nose outside 
the inferior turbinate; i.e., the median wall of the 
antrum. The turbinate is not removed or disturbed. 



Fig. 886. —Submucous resection of inferior turbl 
nate. Anterior view. 















MAXILLARY SINUS. 


185 


withdrawal forcibly pulled forward in order to make the opening as 
large as possible. (Fig. 86.) 

(9) The opening is enlarged in all directions by means of the 
modified double-cutting Wagener punch until it represents ap¬ 
proximately the size of the original flap. (Fig. 87.) 

(10) The antrum is curetted as far as possible, particularly the 
medial floor, the cavity irrigated, and the flap of mucous membrane 
turned in, thus forming a continuous unbroken passage between the 
nose and maxillary sinus. (Fig. 88.) 

(11) Strips of iodoform gauze are introduced, the first one 
covering and pressing on the flap, thus holding it in position against 
the underlying bone. Subsequent strips are placed over this until 
the antrum is loosely filled. 

After-treatment .—After 24 hours, the upper layers of tampons 
are removed and, if the cavity appears foetid, irrigation is practised, 
holding the lower tampon firmly in place with an elevator so as to 
prevent the flap from becoming dislocated. After forty-eight hours 
the lower tampon is carefully removed again, holding the flap 
in place. If, in spite of our endeavors, the flap is rolled out, it must 
be replaced with a new tampon, otherwise granulations will spring 
from the underlying bone and gradually occlude the opening. 

The subsequent treatment will depend upon the secretion; if 
copious, two or three irrigations daily, while if moderate, once dur¬ 
ing the 24 hours will suffice. The patient can easily be taught to 
carry out this procedure himself. Complete healing usually occurs 
in from two to six weeks. If, after six to eight weeks, the secretion 
has not greatly diminished, a radical operation is indicated. 

Advantages: (1) A permanent opening is installed which per¬ 
mits the patient to practise irrigation without pain, as well as 
guards against recurrence during a subsequent attack of coryza 
or influenza. 

Disadvantages: (1) It is exceedingly difficult to accomplish, as 
it is often impossible to preserve the flap. (2) The operation is 
tedious and requires exceptional skill and patience. (3) It pre¬ 
sents very few advantages over the original Krause-Mikulicz and 
possesses the same disadvantages, with the exception of the ten¬ 
dency to closure of the wound in the lateral nasal wall. 

Canfield 9 s Operation r 306 The rationale of this operation is to 

306. Canfield: The Submucous Resection of the Lateral Nasal Wall in Chronic 
Empyema of the Antrum. Journ. Am. Med. Assn., p. 1136, 1908. 




THE ACCESSORY SINUSES OF THE NOSE. 


186 

create an opening in the antero-inferior angle of the antrum, mak¬ 
ing it possible to inspect the greater part of the cavity on an¬ 
terior rhinoscopy. This is accomplished by resecting the inferior 
portion of the bony angle which is formed by the junction of the 
nasal and facial walls. 

Method: 1. Anaesthesia induced by injecting % per cent, cocaine 
in 1-10,000 adrenalin solution along the lateral wall and floor of 
nose and anterior antral wall.* 

2. An incision is made at the junction of the modified skin and 
mucous membrane extending well down into the floor of the nose. 

3. The mucosa and periosteum of the floor and lateral nasal 
wall are elevated upward to the attachment of the inferior tur¬ 
binate, and backward as far as desired. (Fig. 88a.) 

4. The periosteum is loosened and elevated over the anterior 
antral wall. 

5. The bone forming the inferior half of the lateral wall of the 
piriform opening is now removed, together with that portion of 
the lateral nasal wall from which the mucosa has been elevated. 
(Fig. 88b.) 

6. The bony structure of the inferior turbinate removed 
(submucous). 

7. Removal of a portion of the anterior antral wall. 

8. Antrum inspected and curetted. 

9. A flap composed of the mucosa taken from that part of the 
nasal mucosa which is situated beneath the inferior turbinate is 
made and turned into the antrum. (Fig. 88c.) 

10. The deepest portion of the median antral wall is removed. 

11. The antrum and nose packed with vaseline gauze. 

After-treatment consists in removing the gauze on the fourth 

or fifth day, and touching subsequent granulation tissue with pure 
nitrate of silver. Complete healing occurred in from ten days to 
three months. 

Disadvantages: (1) It is too extensive and involves the loss of 
tissue which is important for the nose to properly perform its 
physiological function (bony structure of inferior turbinate). 

2. The submucous resection is difficult, tedious and unnecessary. 

3. The same results can be obtained by a similar operation of 
less magnitude. 

*Canuyt and Rosier have recently published a very comprehensive article On local 
anaesthesia by infiltration, in which they report brilliant successes in operations upon the 
maxillary and frontal sinus. Ann. of Otology, Rhin. and Laryng., p. 1348, 1918. 





• . Fig. 90.—The pre-turbinal method. 2d step. 

Fig 89.—The pre-turbinal method. 1st step Injec- j nc i s i on extending from above the anterior attachment 
tion of Schleich’s solution immediately anterior to tne of the inferior tur binate well into the floor of the nose, 


crista pyriformis. 
















































































































































































































MAXILLARY SINUS. 


187 


This operation always appealed strongly to me, and during the 
application of these methods the following technique seemed to take 
place through a series of gradual evolutions until it has now become 
in our department the standard intranasal operation on the maxil¬ 
lary sinus, whenever an intranasal procedure is indicated. 

10. Preturbinal Method. 306 *' 306b —1. The nasal cavities on both 
sides are cleansed by douches of warm saline solution. 

2. The entrance to the nose, including that portion immediately 
in front of the anterior attachment of the inferior turbinate, both 
above and below, is anaesthetized by painting with a solution of 
cocaine 20 per cent, to which 1-5 its volume of adrenalin chloride 
has been added. 

3. When the anesthetization is complete a solution containing 
novocaine 1 per cent., adrenalin chloride 1/1,000 1 per cent., nor¬ 
mal salt solution 98 per cent., is injected beneath the mucosa on the 
nasal side of the pyriform aperture (Fig. 89) and subperiosteally on 
the facial side of the same structure so that all that region around 
the anterior attachment of the inferior turbinate as well as the inner 
portion of the canine fossa wall will be desensitized. It mil not be 
necessary to use much over 5-6 cc. (80-100 gtt.). (Fig. 89.) 

4. A perpendicular incision is made slightly in front and above 
the anterior end of the inferior turbinate extending well down into 
the floor of the nose. This incision should sever all tissue down to 
the bone. A second incision is made directly back of this, meet¬ 
ing the first one above and below so as to excise a spindle-shaped 
piece of mucous membrane. (Fig. 90.) 

The spindle shaped incision removing a portion of the intervening mucosa will 
largely overcome the tendency towards premature closing of the wound. 

5. After controlling hemorrhage with adrenalin tampons, a 
small elevator is used to elevate the periosteum from the crista 
pyriformis,both externally toward the canine fossa and internally 
toward the inferior turbinate (Fig. 91), until a sufficient portion of 
the bone is exposed. (Fig. 91a.) 

6. The antrum is now attacked with a chisel having a concave 
surface, by applying it to the crista pyriformis, first above and then 
below, removing the loosened bone with a pair of strong forceps. 
(Figs. 92, 93.) While the antrum may be opened by continuing 

306a. R. H. Skillern: Preturbinal Operation on. the Maxillarv Sinus. Laryngoscope, 
Nov., 1914. 306b Harris: Voislawsky, Coffin and Maybaum: Sec. on Laryng., IN. Y. 

Academy of Med. Laryngoscope, p. 425, May, 1918. 




188 


THE ACCESSORY SINUSES OF THE NOSE. 


this method, it is better to substitute • an electric trephine, as a 
smooth, round opening is thus obtained and insures against spicules 
of bone being driven into the sinus. (Fig. 94.) . 

7. Enlarge the opening to any desired size by means of the ordi¬ 
nary curved frontal sinus rasps. 

8. Flush out sinus and after drying pack a thin strip of gauze 
saturated in the cocaine-adrenalin solution and allow it to remain 
five minutes. This not only anaesthetizes the mucosa but also by 
its haemostatic action clears the cavity of blood, and permits a much 
more satisfactory inspection of the interior. (Fig. 95.) 

9. Introduce an ordinary hard rubber ear speculum into the 
opening and thoroughly inspect the antrum for polypoid degener¬ 
ated mucosa, areas of granulation tissue, necrotic spaces, etc. This 
procedure is readily accomplished if sufficient bone has been re¬ 
moved. The nasopharyngoscope is used for inspection of the roof, 
lachrymal region and ostium. 

10. Introduce a curette and remove all portions of diseased and 
degenerated mucosa, not overlooking the floor, posterior-inferior 
and antero-superior angles; the latter can only be reached by a 
right-angle curette. 

11. Again inspect the interior of the sinus, using cotton or 
gauze pledgets dipped in pure adrenalin chloride when necessary 
for cleansing purposes. If all polypoid tissue seems to have been 
removed and the cavity clean,, again irrigate and, after allowing the 
fluid to run out, pack loosely with iodoform tape. 

The entire procedure can usually be accomplished in thirty 
minutes with very little inconvenience to the patient, especially 
if the electric drill is used. Occasionally some oedema over that 
portion of the face follows, but it is painless and disappears within 
twenty-four hours. 

After-treatment: The gauze is removed in 48 to 72 hours, de¬ 
pending upon the amount of secretion; if it remains moderately dry 
it can be permitted to remain even as long as one week. After its re¬ 
moval the cavity should be cleansed by irrigation and lightly re¬ 
packed with iodoform gauze. The treatments are continued every 
second day for ten days to two weeks, when the packing can be per¬ 
manently discontinued. It is remarkable how quickly the discharge 
lessens after the packing is abandoned. 

The treatments (irrigation and insufflation) are continued at in¬ 
creasing intervals for about four weeks, when iij ordinary cases the 



Fig. 91.—The pre-turbinal method. 3d step. Elevat¬ 
ing the soft parts from the underlying bone. 



Fig. 91a.—Anterior crest of bony wall exposed. 



Fig. 92.—Pre-turbinal method. 4th step. Fig. 93.—Pre-turbinal method. 5th step. Us- 

Using the hollow chisel to penetrate the crista pyri- ing the hollow chisel to penetrate the crista pyriformis 
formis into the antrum. Superior penetration. into the antrum. Inferior penetration. 




Fig. 95.—Size of opening into antrum at 
conclusion of operation. 


Fig. 94.—Pre-turbinal method. 6 th step. Pene¬ 
trating into the maxillary sinus with the electric 
trephine. 



MAXILLARY SINUS. 


189 


patient is discharged cured. Certain cases, however, in which the 
permanent pathological changes in the mucosa had necessitated the 
removal of large areas of the lining membrane and in which one of 
the forms of the external radical operation was indicated, require 
longer and more energetic after-treatment to promote granulation 
and cicatrization of the already enfeebled tissues. In these cases 
the discharge continues with little change after the packing has 
been discontinued. After thorough cleansing and drying, one ounce 
of a 25 per cent, solution of nitrate of silver is slowly injected 
and allowed to remain for five minutes, the patient bending the head 
toward the shoulder of the affected side. This is continued every 
second day, the silver solution being used in increasing strength 
(to 75 per cent.), if the weaker solutions do not appear sufficiently 
stimulating. It is surprising how little discomfort these injections 
cause, practically no more than the like quantity of sterile water. 

Precise information regarding the healing and general condi¬ 
tion of the sinus interior can always be obtained by means of the 
nasopharyngoscope, and I know of no condition in which the use 
of this little instrument gives more satisfaction than after this 
operation. Small areas, such as necrotic spots and suppurating 
foci which refuse to heal, are easily located and directly treated 
with pure silver nitrate, then reinspected to ascertain whether all 
parts have been touched. In this manner final and definite healing 
is brought about. During the after-treatment it is necessary to 
always keep the artificial opening of the sinus in mind, as it shows a 
tendency to close with astonishing rapidity. This can be prevented 
by occasionally curetting the edges and applying a caustic. While 
the gauze packing is in place this will not occur, and, indeed, this is 
one of the reasons for the several repackings. After healing has 
been established this opening will gradually close until that side of 
the nose is to all intents and purposes quite as normal in appear¬ 
ance as the opposite side. 

Advantages over the other intranasal procedures: 1. The sinus 
can always be inspected either directly or through the nasopharyn¬ 
goscope, and the progress of healing noted. 

2. The drainage is at the lowest and most accessible point 
reached through the nose. 

3. Local applications directly under vision can be made to dis¬ 
eased areas which have proved resistant to treatment. 


190 


THE ACCESSORY SINUSES OF THE NOSE. 


4. The inferior turbinate is not only preserved in its entirety, 
but remains uninjured. 

5. The operation is practically painless if the anesthetization is 
properly carried out. 

6. The period of healing is considerably shortened and the num¬ 
ber of after-treatments greatly decreased. 


Radical Operative Treatment. 



CALDWELL-LUC METHOD. ’ 

The rationale of this operation is to make a large opening in the 
anterior wall of the sinus through the canine fossa for the purpose 
of inspecting and, if necessary, curetting the diseased mucosa. 

After this a large opening 
in the lateral nasal wall 
beneath the inferior tur¬ 
binate is created in order 
to allow permanent drain¬ 
age of the cavity into the 
nose and the facial wound 
is closed. 

Technique of the Operation.— Instruments required: 1. Two 
retractors (Fig. 96). 2. Scalpels. 3. Several haemostats. 4. Peri¬ 
osteal elevator. 5. Large and small chisels. 6. Nasal sound. 

7. Anatomical forceps. 8. Bone-cutting forceps. 9. Curettes sharp 
and dull. 10. Long nasal forceps for packing. 11. Hammer. 
12. Scissors. 13. Silkworm gut. 14. Needles. 15 Iodoform gauze. 
16. Plain gauze strips. 17. Solution adrenalin chloride 1/1000. 
18. Peroxide of hydrogen. 

1. Etherization of the patient as for any major operation, using 
the Beck-Mueller ether vapor apparatus. 


Fio. 96.—Hajek’s retractor for the holding up of the lip in 
the external operation on the maxillary sinus. 


While certain of our European confreres 31)9 310 in recent years practise -and 
strongly advocate this operation under local anaesthesia, it would seem that, so far 
as the American public is concerned, this is for the most part inadvisable. I 
prefer the local method, whenever possible, on account of the greater facilities 
offered to the surgeon in the control of the blood and secretion by the patient, as 
well as his general cooperation. 


307. Caldwell: Diseases of the Accessory Sinuses of the Nose, etc. N. Y. Med. 
Jour., p. 526, Nov., 1893. 308. Luc: Une nouvelle methode operatoire pour la cure 

radicale et rapid de l’empyeme chronique du sinus Maxillaire. Arch, internat. de Lary., 
May-June, p. 273, 1897. 309. Nager: Die Vnwendung der Lokalanasthesie bei der Radi- 
kaloperation der Kieferhohleneiterungen. Arch. f. Lary., Bd. 19, S. 98, 1907. 310. 

Denker: Zur Radikaloperation des chronischen Kieferhohlenempyems in Lokalanasthesie. 
Verh. ver. Deut. Lary., S. 27, 1910. 




Fig. 97.—The mouth in position for the Caldwell-Luc operation on the maxillary sinus. Dotted 
, line shows position and length of incision. 











Fig. 98. —Incision made through soft parts and periosteum elevated, exposing underlying bone of 
the anterior wall. Pad of gauze at the lower extremity of wound to prevent blood from flowing into the 
pharynx. 





Fig. 99.—Anterior wall removed, showing mucosa of the nasal wall of the maxillary sinus 







MAXILLARY SINUS. 


191 


2. Pack the nostril on the affected side with sterile gauze so 
as to prevent the blood from flowing backward into the choanse and 
being inspirated. 


This is not absolutely necessary, as is seen in the tonsil operations, and may 
be dispensed with if difficult or for any reason not deemed advisable. 


Turn the head toward the healthy side and place retractor in 
position so that the lip is drawn well upward, exposing the alve¬ 
olar process, and place gauze sponge between lip and molar teeth. 
(Fig. 97.) 

3. Make an incision from the canine tooth to the second pre¬ 
molar, care being taken to begin well above the gums so as to allow 
for retraction of the mucosa. (Fig. 97.) This is important on ac¬ 
count of the difficulty experienced in finally stitching these two sur¬ 
faces together. The wound is now enlarged by incising the perios¬ 
teum well under the edges of the external incision. 


Hemorrhage thus far is usually not profuse and is best controlled by gauze 
compress saturated in the adrenalin solution. Occasionally a small artery situated 
in the posterior extremity of the incision will spurt, but is readily seized by the 
haemostatic forceps and torsion applied, thereby controlling bleeding from that 
source. 

4. The periosteum is now thoroughly loosened from the under¬ 
lying bone and held by a suitable retractor. (Fig. 98.) 

5. An opening is made in the anterior wall of the sinus with 
a small chisel. 

This opening should be made at that point where the anterior 
sinus vrall is well away from the lateral wall of the nose, otherwise 
the opening may penetrate into the nose before the antral cavity 
has been reached. 


It is particularly important that all bleeding be controlled at this stage of 
the operation in order that one can judge accurately the condition of the cavity 
on opening. 

6. The opening beneath the periosteum is gradually enlarged 
with a chisel or bone forceps until the greater portion of the ante¬ 
rior wall is removed, care being taken to disclose the anterior 
recesses of the sinus. (Fig. 99.) The mucous lining of the an¬ 
trum is usually lacerated by this procedure; if, however, it remains 
intact, the operator must incise that portion corresponding to the 


192 


THE ACCESSORY SINUSES OF THE NOSE. 


opening in the anterior bony wall. The interior of the cavity is now 
inspected by means of a reflected light. 

It will be necessary to tampon a number of times with long strips of gauze 
before the blood and pus are sufficiently removed to allow inspection. The 
addition of adrenalin or hydrogen peroxide to the gauze will greatly facilitate 
this measure. 

7. Curette these portions which show great degeneration, poly¬ 
poid or otherwise. 

This is a most important phase of the operation, for upon this depends the 
ultimate result and the duration of time required for healing. Seldom is it 
necessary to rob the sinus of all its mucosa, it being far better to curette only 
those portions which show great pathological changes, care being taken to search 
all recesses—particularly the alveolar and palatal—for degenerated mucosa and 
possibly caries of the bone. If too much of the mucosa is removed, the process 
of healing will be greatly delayed; if too little, the result of the operation will end 
in disappointment. However, when one is in doubt regarding the possible regen¬ 
eration of an area, it is better to be on the safe side and remove it. 

8. The next step is to resect that portion of the lateral nasal 
wall lying beneath the inferior turbinate, as well as a portion of 
the turbinate itself, so as to procure drainage into the nose. 

Some question exists as to the necessity of invariably resecting the anterior 
portion of the inferior turbinate. When hypertrophied, presenting the possibility of 
acting as a barrier to free drainage, our course is apparent, but under normal cir¬ 
cumstances we find it unnecessary to sacrifice any portion of this structure. 311 

This is accomplished as follows: Remove the thin layer of hone 
in such a manner as to leave the nasal mucosa intact. (Fig. 100.) 
Pass a probe into the nose beneath the inferior turbinate and note 
where it appears on the lateral wall through the sinus. (Fig. 101.) 
Make a | | shaped flap from the mucosa by two incisions 

with the scalpel, joining them by one cut of the scissors. The 
superior incision should he immediately below the attachment 
of the inferior turbinate. Turn the flap of membrane into the 
sinus and note that it lies smoothly on the floor of the antrum, 
(Fig. 102.) If necessary chisel the remaining base of the bony par¬ 
tition until this is possible. 

The idea of this flap is to form a continuous and permanent outlet into the 
nose by preventing granulations, as well as forming a base for the growth of 
epithelium into the sinus to replace that which was removed by the curette. 

9. Flush out the sinus thoroughly with lukewarm saline solution, 
dry and pack loosely with iodoform gauze. 


311. See Lang, Kuttner, Wagener. Ver. Berl. lary. Gesell., Mar. 22, 1907. 





e —-- 


Fig. 100. —Mucosa of maxillary sinus removed, exposing the bare bone of the lateral nasal wall. The 
chisel in position to remove the bony wall without injuring the nasal mucosa. 



Fig. 101. —The bony wall separating the sinus from the nose removed, leaving the nasal mucosa in situ 
intact. Probe passed into the nose to show the line of incision to make the flap of mucous membrane from 
the nasal floor to the floor of the antrum. 











































































































































































































m 











































MAXILLARY SINUS. 


193 


The packing should be done in such a manner that one end protrudes from the 
nares, the other being in the depths of the sinus. Care must be taken that the flap of 
mucosa lies smooth and well pressed down, otherwise in removing the gauze, it will 
be found crumpled up and an actual hindrance to drainage. Holding this flap in 
place is best accomplished by taking one yard of seamed gauze, drawing the end 
through the nose into the sinus. This is gradually packed (not too firmly, as this 
would increase the subsequent oedema) into the sinus until the cavity is filled, the 
end is packed in the anterior nares. 

10. Close the oral wound with two or three catgut sutures in the 
anterior and posterior extremities of the incision. 



Fig. 102. —The mucosa is incised and the flap turned into the antrum. The position of the inferior turbi¬ 
nate is seen through the opening. 

It is optional whether one applies these sutures or not, as perfect coaptation 
and healing usually result in either case. We have for the most part discarded 
them as unnecessary except where there is a possibility of the mucosa turning in and 
forming a permanent fistula from the removal of too much bone from the alveolar 
ridge. No dressing is necessary. 

Swelling on the side of the face usually begins to appear within twenty-four 
hours and may assume considerable proportions dependning upon the extent of 
the periosteal elevation and the traction exerted on the soft parts by the retractors. 
If this swelling does not show signs of abatement after applications of ice bags 
in three to four days, lavage with warm normal saline solution, through the oral 
opening in the canine fossa, will speedily bring about a reduction with subsequent 
relief to the patient. 

11. Remove the gauze at the end of the fourth day. 

If removed sooner it will adhere tightly to the antral walls, thus causing great 
pain and further inflaming the healing bone and mucosa. At the end of the fourth 
day, the packing is thoroughly saturated with secretion, does not adhere, thereby 
allowing itself to be removed with much greater facility. 

If sutures have been used they should be removed on the fifth 
day, as after that time they show a great tendency to cut through 
the mucosa. As a matter of fact, one or more of the stitches 
usually cuts through or becomes otherwise detached but this does 
not interfere with the ultimate spontaneous healing of the wound. 
The after-treatment consists of daily irrigations of the sinus 
through the nose with warm normal saline solution. 

Hajek 311a has abandoned all forms of irrigation, as he believes it irritates the 
mucosa and causes the secretion to become more profuse. 

311a. Hajek: Lehrbuch, IV Auflage, S. 148, 1915. 





194 


THE ACCESSORY SINUSES OF THE NOSE. 


OPERATION UNDER LOCAL ANAESTHESIA. 312 ’ 312a 

Under certain circumstances, such as pulmonary tuberculosis, 
severe heart and kidney lesions, etc., it may be inadvisable to use 
general anaesthesia. The operation may then be carried out as 
follows: 

Have two solutions prepared, a stronger one of cocaine and 
a weaker one of novocaine. Solution No. 1: Water 5, adrenalin 
5, cocaine 2. Solution No. 2: Water 20, adrenalin 5, novo¬ 
caine 0.25. 

1. Place patient on operating table. Introduce strip of gauze 
saturated in strong solution under and above inferior turbinate. 

2. Anaesthetize between the lip and gum with solution one, 
inject into mucosa above the gums in the site of the incision 1 c.c. 
of No. 2. Inject deeply under the periosteum of canine fossa 1 
c.c. of solution No. 2 and wait five minutes. 

3. Place gauze behind line of incision in mouth and incise the 
mucosa to the bone, extending the cut from the first molar to the 
canine tooth. Retract periosteum of the anterior wall of the sinus. 

4. Make an opening with a gouge large enough to admit a 
gauze strip, so that the cavity may be freed from purulent secre¬ 
tion. 

5. Anaesthetize the interior of the sinus by introducing several 
strips of gauze impregnated by soaking with solution No. 1. Wait 
ten minutes. Remove gauze and inspect cavity with reflected light. 

6. Enlarge opening in the anterior wall to a sufficient size so 
that all the cavity may be inspected. Curette cavity, taking great 
care to remove all degenerated mucosa, particularly in the lachrymal 
region and posterior portion of the floor. 

7. Control hemorrhage by frequent tampons of gauze satu¬ 
rated with adrenalin. Hemorrhage from the bone may be con¬ 
trolled by pressure or by applying a cone-shaped instrument and 
tapping sharply with a hammer. In the event of persistent 
bleeding, apply a tampon of iodoform gauze and defer suturing 
for forty-eight hours. 

8. Insert a trocar through the wall of the inferior meatus and 
introduce scissors into the antrum through the canine fossa, re¬ 
secting the wall for 3 cm. in length and 1 cm. in height. The bony 
portion is removed with the forceps. The completion of the re- 

312 . Luc (231), p. 292, 1910. 3I2a. Von Eicken: Discussion zu Killian's Vortrag 
Ver. Suddeutsch. Laryng., S. 31, 1904. 




MAXILLARY SINUS. 


195 


section of the mucosa is made with a bistoury, thus bringing into 
view the concave surface of the inferior turbinate. 

This may be accomplished even better with Hajek’s swallow¬ 
tailed chisel. The nasal mucosa is pushed aside and usually re¬ 
mains intact; therefore, a pair of forceps is introduced into the 
nose and the mucosa pushed toward the antrum, where it may 
be easily incised with a sharp scalpel. 

9. The turbinate is not interfered with unless markedly hyper¬ 
trophied, as patients will frequently be tormented with crusts 
after removal of a portion of this body. Cleanse the antrum 
thoroughly with gauze saturated in a 50 per cent, solution of per¬ 
oxide of hydrogen. All packing is dispensed with, the cavity 
being thoroughly insufflated with iodoform and the wall closed 
with two or three stitches of catgut. During the first few days 
no other treatment except mentholated vaseline is applied. After 
eight days, when one need have no further fear as to the cicatri¬ 
zation of the wound, wash out the cavity through the nose. 
Lavage is then practised twice weekly, and a cure usually results in 
about four weeks. 

After-treatment .—Rest in bed for twenty-four hours is neces¬ 
sary, the patient being given % gr. morphine, 1/200 atropine, % 
cocaine hypodermically. Unilateral swelling of the face usually 
occurs, which is due to the traumatism, but subsides in twenty-four 
to forty-eight hours. This oedema requires no treatment other 
than hot or cold applications. If gauze has been used it is removed 
through the nose after three or four days, the removal being 
facilitated by frequent injections of hot water into the nostril. 

Zarnico 313 allows the oral wound to remain open and through it removes 
the gauze on the second day. He is thus able to apply a hard rubber speculum 
and inspect the interior of the sinus to ascertain whether the flap of mucosa 
occupies an improper position or other irregularities are present, which may be 
corrected under cocaine anaesthesia. No new packing is applied and the oral 
wound is allowed to close. 

After the fifth or sixth day, when the inflammation has consider¬ 
ably subsided, a rhinoscopic examination should be made to note 
whether the opening is patulous, etc. The cavity may be syringed 
out at this time. 

Subsequent treatments consist in gentle lavage, drying, and 
insufflation of iodoform or pulverized bismuth formic iodide. 


313. Zarnico: Lehrbuch, 3 Auflage, S. 649, 19*0 



196 


THE ACCESSORY SINUSES OF THE NOSE, 


Healing will occur in a few weeks to several months, depending 
upon the amount of mucosa removed from the sinus. If caries 
or necrosis is present, the length of time required for healing 
will he greatly augmented. 

denker ’s method . 314 

Observing a number of failures following the Caldwell-Luc 
method, this author found, on investigation, that they were due 
to overlooked areas of disease situated in the antero-superior angle 
of the sinus. As these are almost inaccessible with the old opera- 



Fiq. 103.—Caldwell-Luc operation completed, Fig. 104.—Denker operation complete with com- 

Bhowing a portion of the facial wall lying intact plete removal of the osseous bridge, thus obliter- 
between the pyriform aperture and the artificial ating the cr.s».a pyriformis. 
opening. 

tion, he conceived the idea of removing the lower portion of the 
angle formed by the junction of the anterior and nasal walls, thus 
making a common opening between the nose and the sinus ante¬ 
riorly. (Figs. 103, 104.) After this was accomplished it was an 
easy matter to reach all portions of the sinus mucosa with the 
curette. 

Prepare as for Caldwell-Luc. 

1. Make incision from wisdom tooth to within % cm. of the 
superior labial frenum. 

2. Elevate the soft parts until the pyriform aperture is ex¬ 
posed to the height of the anterior attachment of the inferior tur¬ 
binate. 

314. Denker: Zur Radikaloperation des chronischen Kieferhohlenempyems. Arch, 
f. Lary., Bd. 17, S. 221, 1905. 




Fig. 104a.—Denker Operation. Incision 
through mucosa and periosteum. 


Fig. 1046.—Denker Operation. After ele¬ 
vation of mucosa and periosteum exposing crista 
pyriformis. 






Fig. 104c. —Denkei Operation. Elevating mu- Fig. 104d.—Denker Operation. Superior cut in crista 
cosa and periosteum from nasal aspect of pyriform pyriformis. 

aperture. 















MAXILLARY SINUS. 


197 


3. Elevate the mucosa of the inferior nasal passage and nasal 
floor for about 4 cm. in depth, keeping the parts separated 
with a strip of gauze, thus preventing the nasal mucosa from 
being lacerated- 

4. Open the sinus in the canine fossa and enlarge opening in all 
directions, particularly the antero-inferior angle, until all parts of 
the interior are brought into view. 

5. Remove the bridge of bone (Fig. 103) leading to the pyriform 
aperture, thus obliterating the crista pyriformis and throwing the 
whole into one large cavity (Fig. 104). 

6. Reset nasal wall below insertion of inferior turbinate for 
approximately half its length being careful to leave no ridges 
between the floor of the nose and the sinus cavity. 

7. Curette thoroughly and finish as with Caldwell-Luc. 

This method possesses the following advantages: 

1. Practically all the sinus mucosa is under direct inspection. 
(The antero-superior angle may be examined with the aid of a small 
postnasal mirror.) 

2. It is less difficult, though more extensive, than the 

Caldwell-Luc. 

3. Inspection can be carried out through the nose after the oral 
wound has entirely healed. 

Comparison of Caldwell-Luc with Denker. 

While the Denker offers certain advantages as mentioned above, 
nevertheless, after the operation is finished one is always impressed 
with the extent and radicalism of the procedure. It often seems 
that the removal of the osseus bridge was unnecessary, not to speak 
of depriving that portion of the upper jaw of some of its natural 
support, and that the patient would have done just as well had it 
been left in place. Under these circumstances, it would appear 
as though we should rely on the Caldwell-Luc method as the one of 
choice even though it is somewhat more troublesome and only 
employ the Denker in those cases which demand a partic¬ 
ularly thorough inspection together with an especially ener¬ 
getic treatment. 

Causes of failure of the radical maxillary operation are: 

1. Insufficient inspection during the operation, with overlooking 
of diseased areas of mucosa. 

2. Installing too small a communication with the nose. 

3. When of dental origin, in overlooking necrotic bone in the 
alveolar process. 



198 


THE ACCESSORY SINUSES OF THE NOSE. 


Causes of subsequent complication: 

1. Premature removal of the gauze packing, causing trouble¬ 
some and often persistent bleeding. 

2. Making the oral opening too large, with the formation of a 
permanent fistula into the mouth. 

3. Forcible application of the curette in the prelachrymal 
recess, causing injury to the tear-duct and permanent epiphora. 

4. Too extensive elevation of the periosteum towards the orbit, 
thus injuring the infra-orbital nerve,, with its attendant conse¬ 
quences (anesthesia, of the cheek, persistent neuralgia). 

5. Excessive resection of the bone towards the roots of the teeth, 
with injury to the dental vessels and nerves. 

6. Excessive retraction of the periosteum with the hooks, caus¬ 
ing a persistent oedema of that side of the face, which may go on to 
a phlegmonous inflammation. 

Modification of the Caldwell-Luc Method. 

It is interesting to note the various transformation stages undergone until 
this operation was finally perfected. While it has been given the Caldwell-Luc 
appellation, nevertheless in reality it is the product of consecutive modifiers. It 
originally sprung from the old Desault 315 operation, which consisted in making 
a simple opening into the sinus through the canine fossa. Kuster, 316 nearly a 
century later, again brought it into prominence, improving the method by modern 
aseptic surgery and rational after-treatment. 

Jansen 317 modified this by curetting away the entire antral mucosa and making 
a flap from the mucous membrane of the .cheek which was packed into the floor 
of the cavity. The wound was held patulous by means of an obturator. Boenning- 
haus 318 made further changes by resecting this flap of membrane from the nasal 
wall, thereby being the first one to create a larger communication between the sinus 
and the nasal cavity. 319 This method consisted in resecting the anterior sinus wall, 
then the osseous nasal wall. The cavity was then entirely curetted and an incision 
made through the anterior and posterior third of the inferior turbinate, the middle 
portion, together with the mucosa, was turned back into the sinus. The oral wound 
was allowed to remain open, through which the dressings were made. Caldwell 307 
and later Luc 308 made use of this method, but made the flap from the membrane 
lying below the attachment of the inferior turbinate. The oral wound was also 
primarily closed after the anterior third of the inferior turbinate had been resected 
to acquire proper drainage. Hajek curetted only those areas of the sinus mucosa 
which appeared pathological and was the first to make a flap. Killian 313 allowed 
the oral wound to close without sutures. Finally, Denker 305 resects entirely the 
anterior wall into the pyriform aperture (Fig. 104). 

315. Desault: (Euvres Chirurg.. p. 156, vol. 2, 1802. 316. Kuster: UeberdieGrund- 
satze der Behandl. von Eiterung in starrwandigen Hohlen, etc. Deutsch. med. Woch., S. 
235,1889. 317. Jansen: Zur Eroffnung der Nebenhohlen der Nase bei chronischer Eiterung. 
Arch. f. Lary., Bd. 1, S. 135, 1894. 318. Boenninghaus: Die Resection d. facialen u. d. 
nasalen Wand. d. Kieferhohle mit Einstulpung von Nasenschleimhaut, etc. Arch. f. Lary., 
Bd. 6. S. 213,1897. 319. Lothrop (303) apparently made but a small opening into the nose. 
320. Hajek: Ueber die Radikaloner. u. ihre Indikationen bei chron. Empyem. d. Kiefer¬ 
hohle. Wiener klin. Rundschau, No. 4,1902. 321. Killian: Bemerkungen zur Radikalopera- 
tion chronischer Kiefer und Stirnhohleneiterungen. Verh. d. Ver. sudd. Lary., S. 22, 1904. 





Fig. 106. —Hajek-Claus bone forceps for creating an opening between the maxillary sinus and nose. 



































MAXILLARY SINUS. 


199 


Results and Untoward Sequelce of the Radical Operations , 322 — 
llie statistics of twelve operators show that in 297 cases 268 were 
completely and permanently healed. Several had recurrences, 
owing to insufficient curettage or to diseased areas which had 
been overlooked. On the whole, the Denker modification gave 
better results than the Caldwell-Luc. 

My own statistics would show that either method thoroughly 
done gives equally good results. As a routine procedure I prefer 
the Caldwell-Luc as it preserves more of the bony structure of the 
face although the Denker is quicker and more easily accomplished. 
The results with either method should be satisfactory if one 
removes only the diseased mucosa but that very thoroughly using 
the little finger to search out all areas of velvety tissue, and 
securing a sufficiently large opening into the nose for aeration 
and drainage. 

Untoward Sequelae: Very few cases have been reported in 
which the convalescence has not been rapid and uneventful. 
Phlegmonous swelling of the cheek due to the stitches may occur, 
and demands removal of the sutures. Neuralgia in the infra¬ 
orbital region has been reported, 323 which can be caused by injury 
to the nerve during the operation or postoperative involvements 
of the nerve in the scar tissue. Anaethesia of the cheek is fre¬ 
quently observed, and usually disappears in a few weeks. Shen- 
osis of the tear-duct with epiphora should theoretically happen 
with great frequency, although but three cases have been reported, 
to which the author can add another. 324 

Permanent fistulas into the mouth have been noted, but are 
usually so small that food cannot penetrate into the sinus. These 
can be prevented by procuring good apposition of the wound 
edges and not removing too much bone toward the alveolar pro¬ 
cess. Osteomyelitis of the superior maxillary has followed three 
times. One case recovered, 325 while two died, as the process 
spread 326 ’ 327 by continuity until the entire skull was involved. 


1 m, 32 , 2 ^ B ?n nmgh SY S 1 : Handbucb du spec, chirurg. des Ohres., etc., Bd. 3, Lief 1-2, S. 128 
19H. 323._J\ i man : bchlussatz zu Bemerkungen zur Radikaloperation chronischer Kiefer 
und Stirnhohleneiterungen. Verh. siiddeutsch Lary., S. 33, 1904. 324. Koffler: Dakryo- 
cystitis chron. purulenta. Mon. f. Ohrenhk., S. 356, 1910. 325. Lubet-Barbon u. Furet: 
O^omyehte dy Maxillaire superieur avec ethmoidite et Empyeme du Sinus. Ann. d. Mai. 
de 1 Onelle, Bd. 2, p. 209, 1905. 326. Thomson: Sinusite Frontale deux cas de Mort post 
operatoire Ann. d. mal de l’Orielle, Bd. 2, p. 409, 1905. 327. Claoue: Osteomyelite Cran- 
lenne envahissante consecutive a une sinusite Fronto-Maxillaire. Ann. d. mal. de POrielle 
—Bd. 1, p. 381, 1906. 




200 


THE ACCESSORY SINUSES OF THE NOSE. 


Immediate and Ultimate Effects of the Radical Operation on the 
Maxillary Sinus. —(Edema and swelling of the face on the operated 
side begin to make their appearance a few hours after the operation 
and persist in varying intensity for four or five days to two or 
three weeks. As a general rule, they should gradually diminish, and 
at the end of ten days have practically disappeared. The incision 
in the canine fossa, if no sutures are used, does not seem to close at 
once in its entirety, hut rather heal from the extremities, and it is 
possible to examine the interior of the sinus by means of an ear 
speculum through the canine fossa for at least one week. At the end 
of ten days the incision should be entirely closed. 

The discharge does not cease at once, but continues rather pro¬ 
fusely while the packing remains in place. After the gauze is re¬ 
moved it still continues for weeks, gradually assuming a change in 
consistency and intensity. At first sanguino-purulent, it soon be¬ 
comes serosanguineous and finally mucoid, gradually becoming less 
and less until it ceases altogether. It must be remembered, how¬ 
ever, that on every attack of acute coryza the discharge becomes 
thicker and more profuse, simulating a recurrence of the disease. 
This will occur until complete regeneration of the mucosa has taken 
place within the antrum. If the secretion continues to be foetid 
after the gauze has been removed, it is very significant that the 
empyema was of dental origin and a diseased root has been over¬ 
looked. A piece of gauze which has failed to come away with the 
packing can also cause this condition. 

The ultimate internal condition of the sinus depends upon the 
extent of the mucosa removed during the operation. If only a com¬ 
paratively small part has been destroyed we can confidently expect 
regeneration over the denuded areas soon to take place. If, on the 
other hand, two-thirds or more has been removed with the curette, 
it will take months before the bone becomes covered, and in the 
meanwhile secretion will be continuous. In any event, the ciliated 
epithelium is replaced by the squamous type. 

When the mucosa has been completely removed the cavity may 
become filled with fibrous connective tissue, which gradually be¬ 
comes ossified. I have been able to prove this to my own satisfac¬ 
tion by making a small opening in the canine fossa of two patients 
for a suspected recurrence who had been operated upon several 
years previously. In both instances the antra were closed with 
spongy bone and healthy, the disease lying in the ethmoid cells. 


PART III. 

FRONTAL SINUS. 


ANATOMY . 328 329 

The frontal sinus, lying in the ascending ramus of the frontal 
bone, takes the shape of a pyramid, with the base lying interiorly. 
(Fig. 107.) It possesses three walls : an inferior, a posterior, and an 
anterior. As the sinus assumes such a variety of sizes and shapes, 
for the purpose of comparison we will accept the arbitrarily-chosen 

normal frontal sinus as suggested 
by Hajek. (Fig. 108.) We will 
thus assume that the normal sinus 
extends from the median line to 
the supra-orbital, notch, and from 
this point by a concave line back 
to the median line.* * 

This may vary from complete 
absence of the sinus 330 to its 
spreading to extensive propor¬ 
tions ; 330a thus it may extend later¬ 
ally to the superior orbital proc¬ 
ess of the malar bone (Fig. 109), 
or superiorly to a point high up 
on the vertex (Fig. 110) 331 or pos¬ 
teriorly to the lesser wings of the 
sphenoid (Fig. 111). The shape 
may be regular (Fig. 112), but it is usually extremely inclined to the 
opposite (Fig. 113), assuming all sorts of fantastic forms and 
directions, depending upon the amount of reabsorption the bone has 
undergone. It apparently is quite independent of its fellow on the 
opposite side, as one side may be fully developed, while the opposite 



Fig. 107. — Lateral view of a medium-sized 
frontal sinus with direct passage into the hiatus 
semilunaris. 


328. Lothrop: Anatomy and Surg ry of the Frontal Sinus. Ann. of Surg., vol. 28, 
p. 611, 1898. 329. Mosher: Anatomy of Frontal Sinus. Laryngoscope, p. 830, 1904. 330. 
Total absence of the sinus on both sides occurred in 3.7 per cent, of 200 specimens (Oppi- 
kofer, Arch. f. Lary., Bd. 19, 1907), and in 5 per cent, of 1200 (Onodi, Die Stirnhohle). The 
frontal sinus is considered absent when no cavity is present at the junction of the orbital and 
squamous portions of the frontal bone. 330a. Weinberger and Purleiss report a case in which 
the vertical measurement was inches and depth 2 % inches. Case of unusually Large 
Frontal Sinus. Ann. Oto. Rhin. and Laryn., Sept., 1920. 331. For various measurements 

of the frontal sinus, see Onodi, Archives f. Laryn., Bd. 14, S. 375, 1903. 

* Morphologically, this cavity is but a prolongation from the anterior ethmoid laby 
rinth which has hollowed out the diploic structure of the ascending ramus of the frontal 
bone. (For substantiation of this statement see anomalies of ethmoid.) 







202 


THE ACCESSORY SINUSES OF THE NOSE. 


side practically fails (Fig. 114); indeed, the two sides are never 
exactly similar. The left side is usually larger than the right. 

It has been stated that reliable conclusions of the extent of 

this sinus can be drawn from 
the prominence of the super¬ 
ciliary ridges. 332 This, how¬ 
ever, has been shown to be un¬ 
reliable by the investigations 
of recent years. 333 ’ 334 

The two sinuses are sepa¬ 
rated by a bony septum which, 
like the crista galli, may be 
considered a direct upward ex¬ 
tension of the nasal septum. 
The relative size and shape of 
the sinuses depend much upon 
the jiosition of this septum, as 
it is capable of showing great 
deviations at the expense of the cavity toward which the deviation 
occurs (Fig. 115). Complete absence of the septum never occurs, 
although one sinus may occupy 
the entire frontal region. In 
these cases but one opening into 
the nose is present. 

Tilley 334 lias shown the extremes of 
deviation which this septum may as¬ 
sume. This is sometimes so marked 
that one sinus overlaps the other (Fig. 

110). The importance of this forma¬ 
tion, from a surgical stand-point, can¬ 
not be over-estimated, for should one 
open the anterior wall above the super¬ 
ciliary ridges, this condition being pres¬ 
ent, he would penetrate into the oppo¬ 
site sinus. 

The septum, however, is 
practically always constant in 
one position, namely, at its origin directly behind the articulation 
of the nasal bones. At this point it is straight and situated in the 
median line, and, should a deviation occur, it takes place above 
this point. 



Fig. 109. —Extreme lateral extension of the frontal 
sinus into the malar bone. 



Fig. 108. —Diagrammatic representation of the 
form and extent of the frontal sinus. (After Hajek.) 
1. Moderate size. 2. Large sinus reaching laterally 
to the malar attachment. 3. Large sinus reaching 
high up in the frontal bone. 


332. Dalla Rosa: Physiologische Anatomie des Menschen, 1898. 333 . Zuckerkandl* 
Anatomie der Nase, Bd. 1, S 325, 1893. 334. Tilley: An Investigation of the Frontal' 
Sinus in 120 Skulls. Lancet, Vol. 2, p. 866, 1896. 









Right frontal sinus 


Frontal sinus 


Orbit 




Fig. 111.—Extension of frontal sinus posteriorly into lesser wings of sphenoid. 











. 1 




















FRONTAL SINUS. 


203 


The boundaries of the normal sinus would then be: in front 
by the supra-orbital portion of the frontal bone, behind by the 
cerebral wall, and below by the orbital plate of the same bone. 



The inferior wall or base is not flat, but is the shape of a small 
inverted pyramid, with an ostium at the apex. (Fig. 107.) This 
aperture is known as the ostium of the frontal sinus. 


THICKNESS OF WALLS. 

Such a degree of difference as was seen in the maxillary sinus 
is not present in this cavity; however, a slight inequality in their 



structure exists. The anterior wall is composed of cancellated 
bone tissue and varies in thickness from 1/16 to % of an inch, 
the heaviest portion being directly over the superciliary ridges. 








204 


THE ACCESSORY SINUSES OF THE NOSE. 


The posterior wall is much thinner, rarely exceeding 1/16 of an 
inch; however, it is composed entirely of compact bone tissue, 
which somewhat compensates for its lack of bulk. This structure 
forms part 'of the wall of the anterior cranial fossa and is in 
contact with the frontal lobe of the brain. The inferior or orbital 
wall is the thinnest, and at its anterior and internal junction, 
directly inside of the orbital ridge, seems to show a decided ten¬ 
dency towards thinness,* for at this point swelling and bulging 
outward of the bone occur in some cases of chronic frontal sinu¬ 
sitis. 335 


DEHISCENCE OF THE WALLS. 

Defects in the osseous structure have been found in every 
wall, including that of the septum, and may be congenital or due 
to trauma, 335 pathological changes, or senile atrophy. 336 The 
most frequent part affected appears to be the orbital. Zucker- 
kandl 337 reports several cases of dehiscence in the orbital plate; 
these were covered with mucous membrane and periosteum, the 
defect being only apparent in the bone; and G-erber 338 and Onodi 
have made similar observations. The anterior wall directly above 
the centre of the eyebrow seems to be a point of predilection, as 
defect in the bone at this place has also been reported by the above- 
mentioned authorities. 

Congenital defects in the osseous formation of the posterior 
or cerebral wall have been reported by numerous observers. 339 
Dehiscence in the septum so that the two sinuses communicate 
has been demonstrated by Killian, 340 and Menzel. 341 Hajek is 
inclined to believe that these perforations are pathological. 


INTERIOR OF SINUS. 

The interior of the cavity is usually not smooth, but shows 
various irregularities, particularly at the junction of the poste¬ 
rior and inferior walls. Partial septa hiding great recesses are 
often seen (Fig. 116), sometimes making the sinus appear to be 


* This was shown to be more apparent than real, the swelling often being due to the 
infection of the emissary veins, which are particularly numerous at this point. 

335. Gerber: Die Komplikationen der Stirnhohlenentzundung, .S. 65, 1909. 336. 

Onodi: Die Dehiscenzen der Nebenhohlen der Nase. Arch. f. Lary., Bd. 15, S. 62, 1903. 
337. Zuckerkandl: Anatomie der Nase, Bd. 1, S. 354, 1893. 338. Gerber (335), S. 152. 
339. Cisneros, Jacques, Mouret, Castex: Cited by Gerber. S. 151, 1909. 340. Killian: 
Ueber communicierende Stirnhohlen. Munch, med. Woch., Bd. 44, S. 962, 1897. 341. 
Menzel: Nebenhohlenanamolien. Mon. f. Ohrenhk., S. 415, 1905. 



FRONTAL SINUS. 


205 


double. 342 According to Sieur and Jacob, 343 these partial septa 
have two seats of predilection: (1) the junction of the anterior 
and posterior walls (commonest); (2) the beginning of the or¬ 
bital prolongation. Long, finger-like projections, reaching high 



Right frontal sinus 


Middle turbinate 


Maxillary antrum 


Fig. 116. —Extreme lateral extension of frontal sinus. Direct connection with antrum. 


Outline of 
right 
frontal 
sinus 


Outline of 
left frontal 
sinus 


Fig. 117. —Frontal sinus sending projections high up into the frontal bone. (After Onodi.) 



up on the forehead or laterally toward the temple, are by no 
means uncommon. (Fig. 117.) It is the residue in these recesses 
that often cause recurrence after a radical operation. (See Opera¬ 
tion.) 

342. M.H.Cryer: Some Variations of the Frontal Sinus. Journ. Am. Med. Assn., p. 284, 
1907. 343. Sieur and Jacob: Fosses Nasalesetleur Sinus, Paris, p. 409,1901. 









206 


THE ACCESSORY SINUSES OF THE NOSE. 


Cases have been reported from time to time in which these 
septa have been complete, thereby forming an enclosed cell within 
the frontal sinus which was isolated. 344 

Hartmann, 345 on the other hand, claims that, embryologically, it is impossible 
for any isolated cell to form within the nasal sinuses, which would seem to be 
entirely correct, even though Boege 346 and Gerber 347 combat this assertion. 

Another form of ridge which sometimes occurs on the posterior 
medial surface is one which is caused by a prolongation of the 
olfactory fissure, and has been termed by Boenninghaus 347a as the 

It can only occur 
when the interfrontal 
septum is deviated pos¬ 
teriorly, thereby allow¬ 
ing the concave ex¬ 
tremity of the olfactory 
fissure to project into 
the frontal sinus in the 
form of a small verti¬ 
cal ridge. During an 
operation the dura is almost certain to be exposed and meningitis 
result. 

The frontal ostium is not constant as regards position, for it may be found 
in the following localities: 348 349 

1. At the superior extremity of the infundibulum. 

2. Anterior and superior to the hiatus semilunaris. 

3. On the roof of the middle nasal passage, at the insertion of the middle 
turbinate. These are only the usual situations of this structure. Anomalies occur 
with great frequency, as it is even not uncommon to see the frontal sinus empty 
into an anterior ethmoid cell (Fig. 119). Onodi 350 reports the occurrence of a 
double nasofrontal duct. 

This ostium may empty directly into the nose or into an en¬ 
closed duct which leads into the nose (ductus nasofrontalis). In 
the latter instance we must pass through two ostia before entering 
the sinus, first the nasal ostium, then the frontal. The ductus 

344. Vacher: Bui. et mem. de la Societe Francaise d’otologie, 1906. 345. Hartman* 
Anatomie der Stirnhohle, Taf. iv, Wiesbaden, 1900. 346. Boege: Anatomie der Stirn- 
hohle, S. 23, 1902. Dissert. Konigsberg. 347. Gerber: Komplikationen der Stirnhohlen, 
S. 158, 1909. 347a. Boenninghaus: Handbuch der Specialten Chirurgie des Ohres etc 
Bd. 3, S. 159, 1912. 348. Heyman and Ritter: Zeit. f. Rhin., Bd. 1, 1909, for an exhaust 
tive treatise on the ostium frontale. 349. Wilson: Variations of the Ostium Frontale 
Trans. Am. Laryn. Assn., p. 178, 1908. 350. Onodi: Die Stirnhohle, S. 13-71 1909 


dangerous area. 


Left frontal 
sinus 



Cribri¬ 

form 

plate 


Fig. 118.—Left frontal sinus opened from above, show¬ 
ing relative position of ostium. 








FRONTAL SINUS. 


207 


nasofrontalis is not present in every instance, but is formed as 
follows: 

The anterior inferior extremity of the frontal sinus is con¬ 
structed by the impingement of the anterior superior nasal spine 


Frontal sinus 


Frontal bulla 
(ethmoid cell) 

Anterior 
ethmoid cell 

Processus 

uncinatus 


Maxillary sinus 



Frontal sinus 


Stylus from 
frontal sinus into 
anterior ethmoid 
cell 


Middle 

turbinate 


Inferior 

turbinate 


Fig, 119. Direct communication of the frontal sinus with an anterior ethmoid cell. 



which helps form the frontal ostium (Fig. 20). The ethmoidal 
bulla is usually situated several millimetres posterior to this 
structure, thereby allowing the infundibulum to expand; however, 
when the bulla ethmoidalis lies anterior to its normal position, 





























208 


THE ACCESSORY SINUSES OF THE NOSE. 


instead of the infundibulum being wide it is narrowed into a duct 
which is closed laterally by the anterior attachment of the middle 
turbinate. (Fig. 120.) This duct (nasofrontal), therefore, has 
two ostia, a nasal and a frontal, and is situated at the superior 
end of the hiatus semilunaris—in fact, is a continuation of this 
structure into the frontal sinus. (Fig. 121.) Its length is vari¬ 
able (% to y 2 inch), depending upon the encroachment of the eth- 



Nasofrontal duct 
Nasal ostium 
Anterior ethmoid cell 
semilunaris 


Anterior 


Frontal sinus 


Fig. 121.—Lateral wall of nose with marked nasofrontal duct. (After Hartmann.) 


moidal bulla. The boundaries of this structure would then be: 
anteriorly, uncinate process, agger nasi, and superior nasal spine; 
posteriorly, lamella of bulla ethmoidalis; internally, anterior 
attachment of middle turbinate; externally, lamina papyracea. 


Relation of the Hiatus Semilunaris to the Frontal Sinus. 

This structure usually lies directly below the frontal ostium 
and forms a direct continuation of the sinus duct into the middle 



FRONTAL SINUS. 


209 


nasal passage. The hiatus assumes two different anatomical for¬ 
mations: (1) direct method of emptying; (2) indirect method. 351 

1. By direct method is meant that the hiatus leads directly into 
the ostium of the frontal sinus without the intervention of any 
anatomical hindrance. (Fig. 122.) 2. The indirect method pre¬ 

supposes the presence of an infundibular cell situated in the hia¬ 
tus, so that it forms a blind ending to this structure, the frontal 
ostium being situated farther above. (Fig. 123.) 

The indirect method is by far the commonest, and is not, as Hajek 352 says, 
the atypical formation. In 176 specimens (including the Cryer collection) ex¬ 
amined by the author the indirect method or the presence of an infundibular cell 
was found in 174 cases. 

Relation of the Frontal Sinus to the Ethmoid Labyrinth. 

As embryologically the frontal sinus is merely an offshoot 
from the ethmoid labyrinth, it naturally follows that this rela¬ 
tion must be a most intimate one. 

In the disarticulated frontal bone 
the frontal sinus appears merely 
as a cavity divided by a septum. 

(Fig. 124.) The ethmoid closes 
in these apertures from below, 
thereby forming the floor of the 
frontal sinus. (Fig. 125.) It will 
thus be seen that the floor of the 
sinus is in reality a portion of the 
ethmoid capsule. Considering 
these formations, it readily will 
be observed that any anomalous 
formation in the anterior ethmoid 
labyrinth will exercise no little 
influence in the configuration of 
the normal drainage passages of semilunaris, 
the frontal sinus. At that place 

where the frontal ostium leads into the nose one of two conditions 
is usually present: (1) an ethmoid cell lies between the ostium 
and the lamella of the bulla; or (2) a second ostium is present 
which leads into an orbital ethmoidal cell. 

This cell has frequently been described as a double frontal sinus, 210 but in 
reality it is only a prolongation of the ethmoid proper, in spite of its being 

351. Killian: Die Stirnhohle. Heymann’s Handbuch, vol. 2, S. 1106, 1900. 352. 
Hajek: Lehrbuch, S. 163, 1909. 

14 



Fig. 122.—- Lateral view of a medium-sized 
frontal sinus with direct passage into the hiatus 









210 


THE ACCESSORY SINUSES OF THE NOSE 


Ostium of maxillary sinus 





Ostiums of posterior 
ethmoid cells 


Fig. 123.—Lateral wall of nose with anterior portion of middle turbinate removed. 



Fig. 124.—Frontal bone and ethmoid capsule disarticulated. 













FRONTAL SINUS 


211 















212 


THE ACCESSORY SINUSES OF THE NOSE. 


situated in the frontal bone. Certain authors 533 * 354 have reported or demonstrated 
cases where cells existed over the orbit but had no ostiums into the nose. All 
these communicated with the frontal sinus and must be considered merely pro¬ 
longations of, or adjuncts to, this cavity. A backward prolongation may occupy 
a portion of the crista galli (Fig. 125a). 

The actual relation of the frontal to the ethmoid sinus depends 
upon the position of the ethmoidal bulla. When this structure 
lies far forward the relation is very intimate, and vice versa, 
(See Anatomy of Ethmoid.) 

Bulla Frontalis. 

A frontal bulla is nothing more than a ballooning upward of 
an ethmoid cell into the floor of the frontal sinus. It possesses an 
individual ostium, and is in no way connected with the sinus into 
which it penetrates. The ostium of the frontal sinus lies to one 
side of this structure. The frontal bulla is formed in one of three 
ways: 1. The lamella of the ethmoid bulla may extend upward 
into the frontal sinus, thus causing a bulging on its posterior 
inferior wall. 2. An infundibular cell may push its way upward 
into the frontal sinus. 3. Lamella of uncinate process may con¬ 
tinue upward and insert on posterior sinus wall. (See Ethmoid.) 

Mucosa of Sinus, Blood Supply. 

The mucous membrane is quite similar to that of the other 
accessory cavities, being exceedingly thin, varying from 22 to 
37 m.m. 354a and adherent to the bone. Mucous glands are even more 
sparcely met with than in the maxillary. The blood supply is 
through the ostium from branches of the spheno-palatine. The 
venous circulation anastomoses in several directions: (a) extern¬ 
ally into facial vein; (b) internally into the nose;(c) posteriorly 
into dura; ( d ) internally into the orbit. This fact must be con¬ 
tinually borne in mind when impending complications threaten. 

SOUNDING THE FRONTAL SINUS . 355 

If a sound be bent at the end two centimetres perpendicularly 
and introduced into the semilunar hiatus, and if it disappears 
until the bend rests on the anterior attachment of the middle tur- 

353. Mouret: Rapports de Papophyse unciform avec les cellules ethmoidales, etc. 
Revue hebd. de Laryng., T. 22, p. 481, 1902. 354. Freudenthal: Nouvele contribution a 
l’operation Radicale de la sinusite Frontale. Arch. Intern, de Laryn.. T. 20, p. 761, 1905. 
354a. Caliceti: The Mucous Membrane of the Frontal and Sphenoid Sinuses. Ref. Int. 
Med. and Surg. Survey, Rhino-Laryngology, May, 1921, 8c-242. 355. Jurasz (Ueber die 
Sondierung der Stirnbeinhohle, Berlin klin. Woch., Bd. 24, S. 32, 1887) was the first rhin- 
ologist to scientifically probe the frontal sinus on the living. 



FRONTAL SINUS. 


213 


binate, the end of the sound is in one of three places: (1) frontal 
sinus; (2) orbital ethmoid cell; (3) frontal bulla. 

A fourth place might be added—the cranial cavity. We will, however, 
leave this out of all consideration, as to penetrate into the brain the probe must be 
on the inside of the middle turbinate in order to strike the cribriform plate. As 
we have seen, the fovea ethmoidalis of the frontal bone completely covers the 
ethmoid capsule, and it would require an unwarranted degree of force to make 
any impression on the comparatively solid bone of these structures, especially if 
one uses the very flexible sound designated for sounding the sinuses. 

TECHNIQUE OF SOUNDING THE FRONTAL SINUS. 356 

The sound is bent in the manner described above (Fig. 126), 
and, after thorough cocainization, is introduced under the ante¬ 
rior third of the middle turbinate. 


In the vast majority 
of instants this portion 
of the turbinate must be 
removed on account of 
the various anatomical 
difficulties which are en¬ 
countered. After this 
structure has been re¬ 
moved, the sinus may be 
reached in over 95 per 




Fig. 126.—Sound bent for frontal sinus. 


cent, of all cases, due allowance being made for pathological conditions (polyps, 
hypertrophies, etc.). 

The point of the instrument is worked behind the tip of the unci¬ 
nate process, and by a gentle forward and upward motion endeavor 
is made to slide it through the nasofrontal passages into the sinus. 

At the first attempt the entrance of the sound will probably be 
arrested by the end becoming caught in the infundibular cell, which 
is almost always present. Under these circumstances it will be 
necessary to slightly withdraw the instrument and endeavor to 
guide the point in a more median direction, thereby gliding over 
the obstruction. If this does not succeed, the sound must be en¬ 
tirely withdrawn, the point bent toward the septum, and the sound- 
ing again attempted. This will usually suffice. If, however, suc¬ 
cess is still unattained, we must either again remove the sound and 
make a different bending or postpone the effort until further resolu¬ 
tion of the inflamed parts occurs.* * 

356. Wells: On Sounding and Irrigating the Frontal Sinus through the Natural 
Opening. Laryngoscope, Vol. 10, p. 262, 1901. 

* The hemorrhage directly following the removal of the middle turbinate, while not 
severe, is often sufficient , to obliterate the landmarks so as often to make sounding impos¬ 
sible. Under these circumstances further attempts must be postponed until bleeding has 
ceased. 









214 


THE ACCESSORY SINUSES OF THE NOSE. 


When the sounding has miscarried with the instrument bent in the usual man¬ 
ner success is often attained by bending the sound more in the arc of a smaller 
circle. In the first instance the sound should be lifted into the cavity; in the latter, 
slid in, as it were. 

For one unaccustomed to sounding the sinus, the great tendency is to direct the 
point toward the orbit and endeavor to push through in this direction. If one 
pauses to consider, it will immediately be seen that the infundibular cells prevent 
passage by this manipulation, and that it is attended with great danger of rupture 
to the orbital plate (which is of tissue-paper thickness in this locality) and penetra¬ 
tion of the orbital cavity. 



Under no circumstances should the slightest force be used— 
at least, no more than is necessary to introduce a like instrument 
into an ordinary unobstructed cavity. 357 

It has previously been mentioned that when the sound disap¬ 
pears up to the curve the point is either in the frontal sinus;, an 

orbital cell, or into a frontal 
bulla. How, then, can we judge 
into which of these structures 
the sound has penetrated? If 
it is in the frontal sinus the 
handle will be resting perfectly 
flat on the lips. A turning 
of this handle, causing free 
external rotation of the lips, 
denotes that it has penetrated 
into a cavity not in the median 
line, therefore an orbital cell. 
If a frontal bulla is present, the 
penetration will not be so deep 
as in the other cavities, as these 
structures rarely attain any great size. A reliable indication for 
the depth to which the sound lias penetrated is to measure with the 
thumb and index-finger on the staff of the instrument, then withdraw 
it and compare the distance by placing it against the external side 
of the nose of the patient. (Fig. 128.) In this way one can note pre¬ 
cisely where the point of the instrument has penetrated. 


Fig. 127.—Sounding the frontal sinus after removal 
of the anterior portion of the middle turbinate. 


NATURAL DIFFICULTIES ENCOUNTERED IN SOUNDING THE FRONTAL SINUS. 

These will be considered in their order of occurrence. 

1. Position of the middle turbinate: When this structure lies 


357. Perforations of the posterior wall and the lamina cribrosa (Mermod, Ann. des 
de Torielle, Tome 22, 1896) have occurred with fatal results. 




FRONTAL SINUS. 


215 


close to- the lateral wall of the nose, or is rolled in or swollen, the 
removal of the anterior third is indicated. 

Uffenorde 3a8 has recently advocated the infraction of this turbinate (first sug¬ 
gested by Killian) in suspected cases, thus avoiding any surgical procedure which 
ultimately might prove to have been unnecessary. He claims to have been able to 
introduce a sound into the frontal sinus after this manipulation as readily as when 
the turbinate was absent. The author has also found this to be extremely practicable. 

2. Approximation of the bulla toward the uncinate process: A 
glance at Fig. 174 will show at once that with such conformation a 
sound could not be made to penetrate the 
natural passages into the frontal sinus. 

3. Abnormally wide uncinate process 
(Fig. 129) : "When the lip of the uncinate proc¬ 
ess is very prominent, the infundibulum must 
lie that much deeper in the hiatus semilunaris. 

Under these circumstances the end of the 
sound will find difficulty in properly engaging 
itself in the right direction to penetrate the 
frontal ostium. 

4. Presence of supernumerary infundib¬ 
ular cells (Fig. 130) : The tip of the sound 
often catches in these cavities, thus adding 
to the normal difficulties of sounding. 

5. Presence of nasofrontal duct (Fig. 

121): While the contour of the sound may 
ordinarily be proper, in the presence of such a 
duct the tip may impinge on the sides and prohibit further ingress. 

6. Presence of a frontal bulla (Fig. 131): If the end of the 
sound catches in one of these structures further introduction is, of 
course, impossible. 

7. Deflection of nasal septum: In the event of a deflected sep¬ 
tum so marked that it is impossible to introduce the sound even in 
the frontal region it will be necessary, particularly in urgent cases, 
to perform a preliminary submucous resection. 

Complications arising during sounding the frontal sinus: 

1. Fracture of the lamella of ethmoid or infundibular cells. As 
these structures are exceedingly thin, this frequently occurs, but 
fortunately has no importance unless the fractured plate of bone be¬ 
comes implanted in the drainage passage in such a manner as to 
partially or entirely occlude it. 



Fig. 128—Measuring the 
distance the sound has pene¬ 
trated against the side of the 
patient’s nose. 


358. Uffenorde (3), 1907. 





216 


THE ACCESSORY SINUSES OF THE NOSE. 


2. Fracture or perforation of tlie lamina papyracea. This ac¬ 
cident is not an uncommon one, but is inexcusable. Fortunately it 
is followed by little disturbance unless infection has been carried 
into the orbit, under which circumstances a phlegmonous inflamma¬ 
tion can readily be excited. 

3. Perforation of the lamina crib- 
rosa can occur through the olfactory 
fissure if the end of the sound is to the 
inside or septal side of the middle tur¬ 
binate. When this occurs the conse¬ 
quences are fataPi!^-5^’ 3580 


Sphenoid sinus- 



•Nasofrontal duct 


•Cell in uncinate 


Uncinate process 


Fig. 129.—Anterior ethmoid cell situated beneath the uncinate process. 

Acute Inflammation : ^Etiology. 


Generally speaking, what applies to one sinus is equally appli¬ 
cable to another, so far as the (etiology is concerned. Regarding 
the frontal, however, individual points may be emphasized. Pre- 

Posterior ethmoid 
cells 


Sphenoid sinus 


Fig. 130.—Extension of entire ethmoidal labyrinth. 

supposing that a general inflammation of the sinus mucosa had 
gone before, the anatomical configuration of the nose is largely 
responsible as to whether the mucous lining of the frontal sinus be¬ 
comes subsequently infected rather than that of the other acces¬ 
sory cavities. If the structures entering into its drainage pas¬ 
sages are favorably situated to insure a patulous opening of 
sufficient size, even though swelling incidental to inflammation 
occurred, we should naturally expect this sinus to react physio- 

358a. Mermod: Lepto-meningite, etc. Archiv. internat. f. Laryng., p. 50, T. 20,1905. 
358b. Weigert; Verh. d. Ver. Siiddeutsch Lar., S. 48, 1895. 358c. Ingals: Commun. to 
Gerber. Cit. in Komp. d. Stirnhohlen, S. 411. 







FRONTAL SINUS. 


217 


logically, at least, in the same manner and degree as its fellows. 
Many factors, however, influence this cavity which do not affect 
the others. We must recollect that the frontal ostium often 
empties into a narrow tube (ductus nasofrontalis), while the 
others have their outlets situated directly in one of the nasal pas¬ 
sages. The nasofrontal duct is susceptible to occlusion by swell¬ 
ing of the anterior portion of the middle turbinate, thus offering 
a more or less impermeable barrier to the outflow of exudate. 



Deviation of the septum exercises no little secondary influence 
in this respect from the mere mechanical obstruction of the middle 
nasal passage, which is doubly emphasized when inflammation 
sets in on that side. 

It would seem that in almost every case of frontal sinusitis deviation of the 
septum toward the affected side is observed. This is particularly noticeable when 
an attempt to sound the sinus is made. One cannot attribute this solely to chance, 
therefore this condition must be an important setiological factor in the causation 
of frontal sinusitis. The maxillary sinus cannot be affected to such a degree, 
because the secretion, after its exit from the ostium, has the chance to flow in any 
direction, forward, backward, and downward; with the frontal the purulent ma¬ 
terial must find its way downward until it emerges from the nasofrontal duct. 






218 


THE ACCESSORY SINUSES OF THE NOSE. 


It must also be remembered that direct primary infection of 
the sinus mucosa is not necessary to set up inflammation within 
the sinus. This can be accomplished by inflammatory approxi¬ 
mation of the mucosa outside of the sinus leading to the ostium, 
thereby preventing the ingress and egress of air. The negative 
pressure thus occasioned, by its sucking action causes the mucous 
lining to react in no uncertain manner, giving rise to serious in¬ 
flammation (if no infection occurs) and to purulent inflammation 
should pathogenic organisms be present. (See Pathology of 
Acute Frontal Sinusitis.) 

Regarding infection from other sinuses, it is, of course, impos¬ 
sible for secretion to flow upward, and the theory of Luc that in 
lavage of the maxillary sinus the inflammatory products are 
forced up into the frontal sinus has been successfully contro-verted 
by Menzel ; 269 yet another possibility for the infection of a higher 
sinus by lower lying cavities remains, i.e., by contiguity. In 
purulent inflammation of the maxillary sinus the continually- 
forming pus constantly exudes from the normal ostium. As a 
result of this continual irritation the mucosa around the orifice 
becomes affected. The infection creeps along the infundibulum to 
the ethmoidal cells and thence to the frontal sinus. 

Presence of foreign bodies in the nose particularly if lodged 
near the hiatus semilunaris may readily set up an infection which 
spreads to the mucosa of the frontal sinus. Tampons are especially 
to be watched while in this region. 3583 

Pathology. 

The mucous of the frontal sinus differs but little from that of 
its fellows, and may be regarded as a continuation of the mucous 
membrane of the nose. During the severer forms of acute coryza 
it is always co-affected with the later, regeneration occurring 
simultaneously in both. When for any reason the inflammation 
persists in the sinus it may take on one of several characters. 

Acute Catarrhal.— The sinus mucosa enlarges many times 
through oedema, and, if the irritation be continued, may so seriously 
encroach upon the lumen of the sinus as to practically obliterate 
the cavity. The surface is sometimes smooth, sometimes uneven 
from localized polypoid swellings. Small punctiform hemor¬ 
rhages are often seen in localized areas. These later may be the 
initial spots of osseous involvement, and are particularly common 
directly above the frontal ostium. The general color of the mucosa 

358d. Rusconi: Frontal Sinusitis from tampon in nose eighteen years. Ref. Cent. f. 
Laryng., p. 51, Feb., 1920. 




FRONTAL SINUS. 


219 


is pale, slightly hyperaamic, or a yellowish-brown. Occasionally an 
area of marked hyperaemia is present. 

Microscopical .—The cilia appear absent in parts, but upon the 
whole are fairly well retained. The superficial glands are en¬ 
larged. The mucosa is enormously thickened, owing to the exten¬ 
sive cedematous infiltration. Some round-cell infiltration is present 
in the stroma, but particularly around the blood-vessels. The 
deeper layers appear but little involved. (Plate 2a.) 

Acute Purulent.— The acute purulent inflammation princi¬ 
pally affects the superficial layer of the mucosa, while in chronic 
disease all of the layers of the mucosa undergo pathological 
changes. 359 The mucosa is diffusely hypersemic, swollen, and 
covered with a greater or lesser amount of purulent secretion. If 
the secretion is thin, no exudate may be present, owing to the 
drainage which has occurred through the ostium. 

Microscopical .—The epithelial surface shows marked papular 
irregularities, occasionally presenting areas of true granulation 
tissue. Large surfaces are present in which the cilia have become 
entirely lost. Round-cell infiltration is particularly marked 
directly below the surface, gradually shading off as the deeper 
layers are approached, except around the blood-vessels and glands. 
The secretion does not consist entirely of leucocytes, but also con¬ 
tains the debris of exfoliated epithelium. (Plate 3.) 

Kuhnt (Fall 3) describes a case of acute gangrenous inflammation in which 
the mucosa was of a grayish-black discoloration, of normal thickness, loose from 
the underlying bone, and covered with a most putrid secretion. 

Diagnosis. 

The accurate diagnosis of this affection usually offers no diffi¬ 
culties. The most prominent symptom being pain in the supra- 
and infra-orbital region, attention is naturally drawn to this 
locality. The pain does not assume the character of an acute 
neuralgia over definite areas, but is rather indefinite and em¬ 
braces, more or less, the entire frontal region, with a culminat¬ 
ing point in and around the sinus. The character is dull, with 
a sense of expansion during the intervals, which quickly assumes 
a throbbing character that affects the whole system during the 
super-acute stadium. 360 There is always a history of an acute 
cold, which rhinoscopic examination will substantiate by the char¬ 
acter of the secretion which is exuding from beneath the middle 
turbinate. Unless there exist anatomical malformations in the 

359. Froning: Beitrage zur pathologischen Anatomie der Stirnhohlenschleimhaut im 
Zustande der Sinusitis frontalis Purulenta. Zeit. f. Laryng., Bd. 4, H. 5, 1911. 360. Com¬ 
pare Coakley: Frontal Sinusitis. Ann. Otol., Rhin. and Laryng., p. 431, 1905. 




220 


THE ACCESSORY SINUSES OF THE NOSE. 


lateral nasal wall or septum this symptom, viz., secretion in the 
middle nasal passage, is invariably present. 

Deviation of the septum towards the diseased side seems to be present in 
many cases. As this contributes not a little towards narrowing the nasal passages, 
it may well be considered an aetihlogical factor of no little importance in pre¬ 
disposing to frontal sinus affection on that side. In itself it may not have been 
able to cause the disease, but with a concomitant infection, the drainage passages 
being so much encroached upon by the septal deformity, the disease may easily 
become stable, whereas, under normal conditions, it would have succumbed to 
the regenerative powers of the sinus mucosa. 

Tenderness on pressure, particularly at the junction of the 
inferior and lateral walls, is an almost pathognomonic symptom. 
It is at this point that the bone is most often affected, and rupture 
occurs. Careful comparison with this point on the healthy side 
should he made, as some individuals are more sensitive than 
others in this locality. Redness and swelling of soft parts some¬ 
times occur, particularly if the infection is virulent. This is the 
symptom described by the older writers as bulging of the anterior 
sinus wall, a condition which we know does not occur unless the 
bone has become badly affected, which, of course, necessitates the 
presence of a disease of some duration. 

Hyperaemia of the middle nasal passage, with more or less 
swelling, is a constant symptom. Partial or complete occlusion 
of the nares is common. General disturbances are present in 
direct ratio to the severity of the disease, although the majority 
of patients do not consider them of sufficient importance to neces¬ 
sitate confinement to bed. 

The general symptoms, unlike those associated with the 
chronic form, are more continuous, although super-acute exacer¬ 
bations, particularly in the morning, are not uncommon. In all 
events, when in doubt, it is our duty to ascertain, so far as pos¬ 
sible, the exact source of the secretion, which may be done with 
the cannula, followed by lavage. If the catheterization is success¬ 
ful and a certain quantity of inflammatory secretion is washed 
out, we are at least sure of our condition, i.e., the frontal sinus is 
diseased. Sounding and catheterization should not be employed 
as a therapeutic measure unless absolutely necessary. (See 
Treatment.) 

Transillumination has proved of little benefit as an adjunct 
to the diagnosis in acute frontal sinusitis. 

Suction by means of negative pressure, when possible to ac- 


FRONTAL SINUS. 


221 


complish, seems to offer considerable aid, as has been shown by 
some observers. 361 ’ 362 

As the hyperaemia of the mucosa is already excessive, theoretically, it would 
appear that more actual harm than benefit would result in adding to the engorgement 
already present but, on the other hand, the circulation may be so stimulated as to 
further rapid resolution. In any event, suction and negative pressure in acute 
sinusitis should be slowly approached and carefully applied until general experience 
has proven its range of usefulness in this condition. 

Symptoms— A cute. 

PAIN AND HEADACHE . 363 364 

It is now generally agreed that these are the most prominent 
symptoms of acute frontal sinusitis. They are present from the 
very inception of the disease, and continue, with greater or less 
severity, until resolution has thoroughly set in, or until the affec¬ 
tion has become chronic. (See Pain in Chronic Form.) The seat 
of the pain is primarily situated in the region of the affected 
sinus, and later radiates over the area supplied by the supra¬ 
orbital branch of the trigeminus. Should the disease continue 
unchecked, other collateral branches of this nerve become sympa¬ 
thetically affected, with the result that pain is experienced in the 
vertex, temporal region, or even the occiput and posterior muscles 
of the neck, although the latter is rare, being more a symptom of 
posterior sinus affec.tions. 

The character of the pain in the beginning is more a feeling 
of pressure and heaviness; as augmentation of the inflammation 
occurs, this gradually assumes the character of a true neuralgia, 
not only being sharp, burning, and lancinating, but dull and throb¬ 
bing as well. It does not run an even course, but is subject to the 
utmost vagaries without any apparent reason. These remissions 
and exacerbations are influenced by almost every act of the indi¬ 
vidual; thus, if the patient was in a state of comparative quiet 
and suddenly stooped or quickly turned the head, a severe head¬ 
ache lasting several hours might readily occur. No matter what 
intensity the pain assumes, it is invariably augmented by blowing 
the nose, coughing, and straining at stool, or, in fact, any condi¬ 
tion which tends to cause congestion of the head. 

This explains why alcohol in any form is always followed by acute exacerba¬ 
tions of the headache in sinus disease. This holds good for all the accessory 
sinuses, but particularly the sphenoid. 

361. Sonderman (152): Munch, med. Woch., No. 1, 1905. 362. Mosher: Chronic 
Suppuration of the Frontal Sinus. Laryngoscope, p. 347, 1907. 363. .Kopetzkv: The 
Diagnostic Significance of Headache in Diseases of Nose, etc. N. Y. and Phila. Med. Joum., 
Dec. 2, p. 1159, 1905. 364. C. R. Holmes: Head Pains Caused by Inflammation of the 
Accessory Sinuses. Ohio State Med. Journ., Feb., 1906. 



THE ACCESSORY SINUSES OF THE NOSE. 


Sometimes the pain reaches such an intensity that the sufferer 
paces up and down the room holding the head between his hands, 
fearing that he will lose his reason. Fortunately, these acute 
exacerbations remit with the same celerity with which they 
appear, and without any apparent cause. The usual history of 
these cases is that, while headache is a constant symptom, the 
intense pain is always felt shortly after arising in the morning, 
and continues for one to three or four hours, remitting as sud¬ 
denly as it appeared. This phenomenon may be explained in three 
ways. 

1. On account of the recumbent position during the night the 
blood-pressure is equalized, the blood having freer access to the 
head. As a consequence, the already inflamed sinus mucosa 
becomes turgid almost to the point of bursting, the two surfaces 
from the anterior and posterior walls coming in close apposi¬ 
tion, so as to fairly encroach upon one another. The lumen of 
the sinus is obliterated, so that little or no secretion can be 
present. This can only occur in the early stages of the affec¬ 
tion, before mucopurulent or purulent secretion is established. 

2. While the patient is in bed the ostium of the sinus is in an 
unfavorable position to allow the accumulating secretion to 
escape. This purulent collection, by its presence, irritates the 
mucosa, so that when the patient arises the sinus is not only 
full of pus but the hyperaemia, if possible, is even greater, at 
least around the ostium. The weight of the pent-up secretion 
causes more venous stasis, consequently the pain is intense until 
relief is afforded by natural or artificial evacuation of the sinus 
contents. 

3. In this condition the fault lies primarily with the drainage 
passages, the sinus mucosa being secondarily affected. It is met 
with more often in the chronic forms where permanent tissue 
changes have taken place, although the acute are by no means 
exempt. The changes are as follows: During the night the various 
structures comprising the drainage passages become hyperaemic 
and swollen to such an extent that the air changes in the frontal 
sinus are entirely suspended. As a consequence the blood absorbs 
the oxygen therein contained, the volume of C0 2 given off being in 
disproportion; a condition of negative pressure in the sinus re¬ 
sults, which causes intense pain until the sinus is again aerated. 865 


365. Robertson (131), p. 645. 



FRONTAL SINUS. 


223 


I have been able often to produce this pain artificially in the maxillary sinus 
by needle puncture and by fitting on a large syringe and applying negative pres¬ 
sure. This will not succeed if there is free ventilation through the ostium. 

A differential diagnosis of these conditions can be made. In 
No. 1, lavage or ventilation will not relieve the pain. Reduction 
of the mucosa must be accomplished by means of ice-bags before 
an amelioration will set in. In No. 2 lavage, or even aeration 
which allows the secretion to escape, will speedily cause a reac¬ 
tion for the better; while in No. 3 aeration alone will bring instant 
relief. This condition will be recognized at once by the complete 
absence of all secretion. 

Headache from negative pressure seems to exhibit some indi¬ 
vidual peculiarities, in that it follows the course of distribution 
of the anterior nasal nerve, producing a headache in the orbit, 
frontal sinuses, and anterior portions of the nose. 366 

The eye on the diseased side seems to be peculiarly affected by 
the pain, particularly in the acute form. This is especially ob¬ 
served in the internal muscles when the patient rolls the eyeball 
upward and inward. Continued reading or attendance on the the¬ 
atre will always intensify the prominence of this symptom, as 
well as cause the eye to feel larger and heavier than on the unaf¬ 
fected side. Mental exertion even during the quiescence of the 
disease will markedly aggravate the tendency toward an acute 
exacerbation of the headache. 

TENDERNESS ON PRESSURE AND PERCUSSION. 

These signs rarely fail. Sensitiveness on pressure on the 
pathognomonic point (the inferior wall near the inner canthus of 
the eye) is always present, and occasionally one is able to elicit 
marked tenderness over the entire anterior wall. Percussion will 
also bring out an area of soreness which is considerably greater 
than on the opposite unaffected side. 

The temperament of the individual must be largely taken into account when 
applying these tests, as neurotic individuals have a decided tendency to over¬ 
exaggerate the symptoms brought out by these methods. Coakley 867 cites a case 
in which pain on percussion over the frontal surface of frontal bone and intense 
pain on pressure over the orbital plate of the frontal were present, yet on opera¬ 
tion he found that the patient did not have any frontal sinus. 


366. Brawley: The Headache of Non-Suppurative Frontal Sinusitis. Laryngoscope, 
p. 716, 1908. 367. Coakley: Frontal Sinusitis. Ann. Otol., Rhin. and Lary., p. 431, 

Sept., 1905. 



224 


THE ACCESSORY SINUSES OF THE NOSE. 


SECRETION. 

At the commencement of the acute attack no secretion is 
formed. The circumstances are precisely analogous to those of 
an acute coryza: at first dryness, then hypersemia, and, finally, 
formation of secretion. The character of the latter is at the on¬ 
set thin, serous, and watery, and, of course, cannot be distin¬ 
guished from that of the nasal mucosa. Mucoid, mucopurulent, 
and, finally, purulent secretion (sometimes streaked with blood) 
quickly follow in their successive stages, depending upon the in¬ 
tensity of the disease. As the nasal mucosa regenerates, the 
secretion from the frontal sinus is more and more apparent. If 
the disease runs its course, the secretion will retrograde in its 
manner of appearing; thus the final stage will terminate in the 
serous character of the onset. This usually requires between ten 
and fourteen days. 


LOCALITY OF SECRETION. 

In the acute form of this affection the secretion appears in the 
typical place, i.e., between the middle turbinate and the lateral 
wall of the nose. This applies only when the patient is in the 
upright position, for while reclining it would naturally follow the 
law of gravity and flow in the channels of least resistance or into 
the nasopharynx. 

The reason why the secretion appears in the typical place so 
much more frequently in this form than is seen in the chronic 
form is that hypertrophies and polyps have not as yet had time 
to form, consequently, with the exception of the hypersemia, we 
have no obstruction to divert the flow from the natural channels. 

The discharge during the acute stadium is fairly constant, and 
does not always show the remissions and intermissions that are 
so common with the chronic. If, however, it tends to diminish 
and the pain becomes more apparent, we can he sure that some 
obstruction to the outflow has occurred with no real diminution 
in the secretion. If, on the other hand, the pain diminishes simul¬ 
taneously with the discharge, regeneration of the mucous mem¬ 
brane is taking place. 

APPEARANCES OF THE NOSE. 

Internal .—Rhinoscopic examination will show more or less 
swelling and hypersemia of the general nasal mucosa, depending 


FRONTAL SINUS. 


225 


upon the degree of regeneration which has occurred. If the 
Schneiderian membrane presents little evidences of the preced¬ 
ing coryza, the hyperaemia will be limited to the structures form¬ 
ing and contained in the middle nasal passage (uncinate process, 
ethmoidal bulla, and middle turbinate). Changes in the anterior 
extremity of the middle turbinate are constant, ranging from a 
hyperaemia to beginning polypoid hypertrophies. The uncinate 
process is also involved in this swelling, which was formerly 
attributed of pathologic importance in frontal sinus empyema. 368 
Generally speaking, the nares of the affected side is partially or 
completely occluded, so far as respiration is concerned, this being 
one of the chief complaints of the patient. 

Post-rhinoscopic examination reveals nothing abnormal, unless 
the purulent discharge meets with some obstruction to the outflow 
from the anterior middle nasal passage. Under such circumstances 
it will he seen issuing into the choana over the posterior extremity 
of the inferior turbinate. 

External .—Redness and dermatitis of the external nares are 
observed when the secretion is profuse, but, as these occur quite 
as frequently with a had cold from the constant use of the hand¬ 
kerchief, no special import can he attributed to them. 

EXTERNAL APPEARANCE OF THE SINUS. 

Usually no difference can be distinguished from that of the 
opposite side. In rare instances, however, a condition arises at 
that portion of the floor of the sinus above the inner canthus of 
the eye. This has been described as bulging of the wall. As a 
matter of fact, this bulging is often more apparent than real, being 
due to a periostitis over this region. 

Kuhnt has shown that this portion of the sinus wall contains many perforat¬ 
ing veins which lead from the sinus mucosa to the external periosteum. During 
infection of the sinus cavity these vessels may carry the inflammatory products 
outward, depositing them at their point of exit from the cranium. I have grave 
doubt that actual dilatation in this locality ever occurs with acute frontal sinusitis. 


DISTURBANCES IN OLFACTION. 

Anosmia occurs on the affected side, which is hut a natural con¬ 
sequence, being purely mechanical, due to the swelling of the 
middle turbinate against the septum, thereby occluding that por- 

368. Kaufman: Ueber eine typische Form von Schleimhautgeschwulst, etc. Mon. f. 
Ohrenhk., S. 13, 1890. 

15 



226 


THE ACCESSORY SINUSES OF THE NOSE. 


tion of the olfactory fissure which contains the sensory endings of 
the olfactory nerve. If sufficient space between the aforesaid struct¬ 
ures remains, the secretion finds its way upward by capillary attrac¬ 
tion, thereby augmenting the difficulties of the odors in finding their 
way to this region. Other disturbances, such as subjective cacosmia, 
in contradistinction to the chronic form, are rare. 

General disturbances which accompany an acute infection do 
not differ materially in the frontal sinus from a similar condition in 
any of the others. I cannot recollect any one symptom which is pre¬ 
eminently associated with this cavity, and what has been said under 
general symptoms (p. 54) will apply here equally as well. 


Pkognosis. 

The prognosis of acute frontal sinusitis is good, if sufficient 
drainage be established early in the disease. The setiological fac¬ 
tor of complications depends far more on the interference with 
drainage than upon the virulence of the infection.* The position of 
the ostium, situated at the lowest extremity of the sinus, is an im¬ 
portant factor in this respect, not only to allow the escape of any 
fluid which might be secreted but also to permit the passage of air 
and thorough aeration of the sinus. This is proved by the im¬ 
mediate relief experienced when the ostium and drainage passages 
are freed with evacuation and ventilation of the cavity. 

The vast majority of acute frontal sinusitis heals spontaneously 
and practically all (95 per cent.) after free drainage has artificially 
been established, either through infraction of the middle turbinate 
or resection of its anterior third. 

We must remember that the frontal sinus shows even greater tendency toward 
spontaneous healing than the maxillary. The resolution which occurs without arti¬ 
ficial aid may be slower and be followed by slight permanent changes (catarrh) of 
the mucosa, so that during the subsequent exposures to cold and wet the patient comes 
to note that the u cold in the head ” shows a marked predisposition to settle over 
the eye. 

In, one might say, all of those cases in which complications 
occurred or which had become chronic neither of these intranasal 
procedures had been applied, or, if so, their application had been 


* This does not apply to sinus disease from internal causes, such as scarlet fever. 



FRONTAL SINUS. 


delayed until too late for therapeutic benefit. The more fre¬ 
quently acute attacks of frontal sinusitis occur, just that much 
more liability predominates for the disease to become chronic. 

COMPLICATIONS.* 

Complications occur less frequently in this form of a frontal 
sinusitis than in the chronic, being due more to a direct extension 
of the inflammatory process than to mechanical causes. The 
mode of transmission to neighboring parts is through phlebitis 
of the perforating veins. Spontaneous rupture is rare, for the 
reason that such an occurrence does not have time to formulate, 
owing to the rapidity with which the acute complications mature. 

PERIOSTITIS AND OSTITIS . 369-371 

These appear to be among the most frequent types of compli¬ 
cations occurring in acute frontal sinusitis. Gerber found them 
to occur as often in acute as in chronic; that is, in fifty-two cases 
of ostitis and periostitis complicating frontal sinus disease 
twenty-six occurred during the primary or acute stadium. The 
walls most frequently affected were the orbital or inferior. 


CARIES AND NECROSIS . 372 ^ 375 

These affections can only he considered an advanced stage of 
the preceding, as ostitis and periostitis must naturally he primary 
to them. Gerber considers it not an uncommon occurrence to find 
them appearing in the course of acute frontal sinus empyema, 
although not so frequent as the milder affections of the bone. 
Such has not been the experience of the American 376 and Eng¬ 
lish 377 rhinologists, as well as some of his own German col¬ 
leagues. 378 379 

* For an elaborate treatise on this subject consult Gerber. Die Komplikationen der 
Stirnhohlenentzundungen, 1909. 

369. Axenfeld: Ein Beitrag z. Path. u. Therap. der Frontalen, etc. Deutsch. med. 
Woch., No. 40, S. 714, 1902. 370. Schmiegelow: Einige seltenere klinische beobachtungen 
die Nebenhohlen, etc. Zeit. f. Ohrenheilk., S. 293, 1903. 371. Wilson: Abscess of Frontal 
Sinus, with Perforations of Outer and Inner Tables. Australian Med. Gaz., Oct. 20, 1898. 

372. Ingals: Empyema of Frontal Sinus. Joum. Am. Med. Assn., p. 233, July, 1901. 

373. Tilley: Two Cases of Chronic Frontal Sinus Empyema, etc. Brit. Med. Journ., 

p. 648, Sept., 1900. 374. Castex: Sinusite frontale infectieuse, sequestres, etc. Arch. 

Internat. de Lary., T. 2, p. 1055, 1906. 375. Winckler: Weitere Beitrage zur Chirurgie 

der Nebenhohlen, etc. Zeit. f. Ohrenhk., Bd. 40, S. 295, 1902. 376. Richards: Personal 

Experiences with Frontal Sinus Empyema. Am. Journl. of Med. Sciences., p. 841, i905. 
377. St. Clair Thomson: Frontal Sinusitis—Two Cases of Death after Operation. Lancet, 
Aug. 12th, p. 431, 1905. 378. Jansen: Zur Eroffnung der Nebenhohlen der Nase bei 

chronischen Eiterung. Arch. f. Laryn., Bd. 1, S. 142,1904. 379. Maljutin: Zur Kasuistik 
der Stirnhohlenentziindung. Arch. f. Lary., Bd. 19, S. 363, 1907. 



228 


THE ACCESSORY SINUSES OF THE NOSE. 


OSTEOMYELITIS . 380-382 

Infection of the diploe of the bone is caused by retention of an 
especially virulent secretion and traumatism (operative or other¬ 
wise), and occurs in two forms: circumscribed and diffuse. 

Circumscribed. —This begins with oedema, pain, especially on 
pressure over a circumscribed portion of the sinus wall, and gen¬ 
eral systemic manifestations (fever, prostration, etc.). The path¬ 
ological process gradually spreads by continuity until the bounda¬ 
ries of the ethmoidal capsule are reached, where it ceases. Thor¬ 
ough resection of the diseased bone will usually result in a cure. 382 * 

Diffuse. —This form knows no boundaries, but continues un¬ 
abated until the entire osseous covering of the brain is affected, 
unless cerebral infection and death halt the progress of the dis¬ 
ease. Operations, even though extensive, offer no bar to the 
progress of the infection. 383 

The mechanism of this infection will be better understood if 
one studies Fig. 132. It will be noted that these canals through 
the diploe of the bone serve for the transmission of large veins 
which carry the blood from the surrounding parts. The veins 
occupying these canals have their endings both externally and on 
the dura mater to communicate with the venous sinuses of the brain. 
Therefore, infection may cause not only inflammation of the bone 
along their tract but also a subperiosteal or extradural abscess, 
or both. The various sutures do not necessitate a break in the 
continuity of these canals, as the veins penetrate from one bone 
to another at the point of articulation. 

When the diploe of the bone in a circumscribed portion be¬ 
comes infected, sooner or later one of these canals is reached by 
the purulent process and the infecting micro-organisms are car¬ 
ried to distant points of the cranium through the blood current. 
If the infection is so virulent that it overcomes the natural resist¬ 
ing powers, a general osteomyelitis of the cranium results; other¬ 
wise, the disease manifests itself locally at the point of the 
original infection. 

Pathology.— In an advanced case spongification of the osse- 

380. McKenzie, Dan.: Diffuse Osteomyelitis From Nasal Sinus Suppuration. Journ. of 
Laryng., Rhin. and Otol., p. 6, 1913. 381. Ropke: Ueber die Osteomyelitis des Stirnbeins, 
etc. Verh. s. Deutsch. Otolog. Gesell., S. 162, 1907. 382: Luc: Complications cranienneset 
intracraniens des antrities frontales sup., Ann. d. Mai. de l’oreillej etc.," No. 35, n. 265 
1909. 382a. Harris: Vertex Headache, Preceding and following an Operation for Frontal 
Sinusitis. Laryngoscope, p. 887, 1918. 383. Tilley: Fatal Case of Chronic Frontal Sinus 
Empyema. Lancet, Aug. 19, p. 534, 1899. 







FRONTAL SINUS. 


229 



ous tissue along the line of infection is prominent. The bone 
is bathed in pus not only on its external but internal surface 
as well. The canals are filled with purulent secretion, and certain 
portions may have become melted together, forming intradiploic 
abscesses. At the external points of suppuration the veins are 
thrombotic. 

Symptoms.— Clinical manifestations appear at the very onset 
of the disease. The part overlying the inflammatory process be¬ 
comes cedematous and is exquisitely painful on the slightest pres¬ 
sure. The abscess soon 
points and ruptures, 
the underlying bone ap¬ 
pearing spongy and in¬ 
filtrated with pus, some¬ 
times throwing off se¬ 
questers. Unless the 
process is immediately 
arrested new foci of in¬ 
fection appear above, 
which also suppurate 
until the entire cranium 
is involved. (Fig. 132.) 

Another form has 
been described in which 
the original focus of 
suppuration appears to 
heal, followed by secon¬ 
dary foci, occurring con¬ 
secutively on different 
portions of the vertex. 


Fig. 132. —External table of skull removed, showing the canals 
of Breschet. (After Breschet.) 


These severe infections practically always terminate mortally 
in general septicaemia, thrombophlebitis of one of the large intra¬ 
cranial veins, or meningitis. 


ORBITAL COMPLICATIONS. 384 ' 385 

When orbital complications associated with acute frontal sinus¬ 
itis occur, the symptoms usually set in with violent manifesta¬ 
tions, due to the diffuse inflammation of one or more walls. As a 

^ 8 r 4 *Mf >aunz: -^ urc ^ Nasenkrankheiten verursachte Augenleiden. Knapp. Arch. f. 
Augenheilk., S. 380, 1905. 385. Lafon: Cellulite orbitaire consecutive a un empyeme aieu 
du sinus frontal. La Clinique ophthal., p. 71, 1906. 




230 


THE ACCESSORY SINUSES OF THE NOSE. 


result of the rapidity of this process, perforation of the walls oc¬ 
curs and the infectious material is quickly transported to the 
neighboring tissues, especially those of the eye. All varieties of 
orbital and ocular conditions have from time to time been reported 
following acute frontal empyema. 

These include inflammation of orbital cellular tissue without 
suppuration, orbital abscess and fistula, hyperaemia of superior lid, 
conjunctivitis, chemosis, phlegmon of lid, infiltration of the muscles, 
immobilization of the bulb, exophthalmos, and even panophthal¬ 
mitis. 


INTRACRANIAL COMPLICATIONS. 

Intracranial complications coincident with acute frontal sinus¬ 
itis rarely result from an actual breaking down of the bony walls 
with perforation, but rather from the infection being carried to the 
meningeal structures through the venae perforantes. 386 The actual 
cause of the complication appears to be an especial virulence of the 
infecting micro-organism rather than to stagnation of the secretion 
in the sinus under pressure. The following conditions appear to be 
the most common: Subdural abscess, 387 extradural abscess, 389 lepto¬ 
meningitis, 388 thrombophlebitis, 390 and brain abscess. 391 

Treatment. 

The treatment to be instituted when a patient presents himself 
with acute frontal sinusitis will depend upon what phase the affec¬ 
tion has assumed. If threatening symptoms of stagnation pre¬ 
vail, naturally a much more energetic course of treatment must be 
applied than under ordinary conditions. We shall, however, con¬ 
sider the affection from the case which is usually met with in private 
practice. 

Patients seldom individualize the frontal sinus as the seat of 
the disease, but rather complain of a severe cold with prominent 
symptoms referable to this region. As a matter of fact, this is 


386. Schulze: Rapid verlaufende Erkrankungen der Nasennebenhohlen mit cerebralen 
complication (Fall 2). Beit. z. Anat., Phys., Path u.Ther. d. Ohres, etc., Bd. 4, S. 48,1911. 
387. Hinsberg: Ueberd. Infectious mechanismus bei Meningitis nach Stirnhohleneiterung. 
Ver. d. Deutsch. Otol. Ges., S. 191, 1901. 388. Hopfgarten: Akutes Empyem beide 
Stirnhohlen nach Influenza (Fall 3). Deutsch. Zeit. f. Chirurg., S. 498,1896. 389. Freuden- 
thal: Endocranial Complications of Nasal Origin. (Case 1.) Laryngoscope, p. 60, 1910. 
390. Denker: Rhinogener Frontallappen Abscess in der Stirnegend, etc. Arch. f. Lary., 
Bd. 10, S. 410, 1900. 391. Gerber: Rhinogener Himabszess. Arch. f. Lary., Bd. 16, 
S. 208, 1905. 




FRONTAL SINUS. 231 

precisely the condition we have to deal with. The nasal mucosa 
is swollen and inflamed together with that of the sinus on the af¬ 
fected side. To successfully combat this condition our indications 
are twofold: (1) to procure drainage; (2) to reduce the swelling and 
inflammation, thereby producing resolution. General treatment 
should take far precedence over any local manipulations at this 
stage of the affection. 

From my experience, sounding and attempts at catheterization at this par- 
ticular time do more harm than good, and are distinctly contra-indicated. If we 
remember that the tissues are engorged with blood, the condition being one of 
acute diffuse inflammation, and that the sparse secretion is merely an inflam¬ 
matory product, for the time being having nothing in common, pro or con, with 
the ultimate course of the affection, we can readily see how little the evacuation 
of this secretion would influence the result. These things being considered, the 
certain amount of traumatism from the attempts at passing a catheter which 
inevitably results even in the most skilled hands will but aggravate the inflam¬ 
mation and prove detrimental to immediate resolution. 

Two courses are open to accomplish this end. If the patient 
is a woman, she should be ordered to bed. With males this advice 
will usually be rejected, particularly if the headache be not marked; 
however, complete rest may be obtained in another way, i.e., 
through the Turkish bath. By this means we can obtain a double 
benefit—by the sudorific action of the bath, as well as the rest in 
bed incidental to it. The patient then should be sent to an Oriental 
bathing establishment, with orders to remain in the caldarium 
(hot room) as long as possible, or until the heart-beat becomes 
distinctly rapid or symptoms of weakness appear. Neither a 
massage nor cold plunge should follow, but the body should be 
wrapped in a blanket, and the patient retire to bed, remaining there 
until morning. He should be given two prescriptions, one for calomel 
gr. iv, with the same quantity of bicarb, of soda and sugar of milk 
made into one powder, to be taken immediately on retiring, the 
other for aspirin 3ii, put up in twenty grain powders. One of these 
should be taken before the bath, another shortly afterward, and the 
remaining two hours apart when awake. On the following morn¬ 
ing the congestion is, for the most part, relieved. The aspirin is 
continued every two hours, care being taken to withdraw it at the 
first symptoms of gastric irritation. 

This statement cannot be ignored, as we have frequently seen cases of indiges¬ 
tion (eructations of gas and epigastric pain) persist for months, despite all treat¬ 
ment, following the continued ingestion of either aspirin or novaspirin. 


232 


THE ACCESSORY SINUSES OF THE NOSE. 


The patient is cautioned not to overexert himself, either men¬ 
tally or physically, and, above all, to avoid all alcohol, tobacco, or 
draughts wherein there is a possibility of reinfection. 

A similar course of home treatment may be established for the 
gentler sex, the above being, for the most part, inapplicable. She 
must be confined to bed, with ice-bags to the forehead and hot-water 
bags to the feet. Hot fomentations by means of wash rags wrung 
out in hot water are occasionally more comfortably borne by the pa¬ 
tients than the ice-bags. The action of heat is similar to that of cold 
in acute inflammations; therefore, theoretically, either would seem 
to answer the purpose. Our preference lies with the cold applica¬ 
tions, particularly if there is a tendency toward febrile manifesta¬ 
tions. Aspirin gr. xx every two hours as before. General sweating 
may be induced, but this is rarely necessary. Calomel at bedtime 
must not be overlooked. Twenty-four hours is approximately the 
time in which we may expect the hyperacute symptoms, to disappear. 

So far as local treatment is concerned, generally speaking, we look upon it 
rather with disfavor at this time. Cocaine and adrenalin are the only two sub¬ 
stances which will contract the tissues. The cocaine acts feebly in this stage, even in 
stronger solutions, and the adrenalin, while producing temporary ischaemia, causes 
reactionary swelling after the first effects have worn off, leaving the patient even 
more uncomfortable, if possible. Not only that, but often individuals show a decided 
idiosyncrasy toward this drug, it causing the most miserable symptoms, simulating 
an acute coryza. If some local application is demanded, a nasal douche of normal 
salt solution as hot as can be conveniently borne should be tried. Steam inhalations 
may be substituted for the warm saline douches, particularly if the latter do not ap¬ 
pear to be effective. These should be repeated every hour and applied for at least 
five minutes at a time. As some little effort on the part of the patient is required to 
successfully carry out this treatment, it is only usually effectively accomplished after 
several inhalations have been taken. This will often allay the inflammation, and has 
the advantage of being more or less permanent. 

These treatments will usually suffice to break up the acute con¬ 
dition. The after-treatment will consist in the daily application of 
cocaine to the region of the middle nasal passage, with subsequent 
lavage, the rationale being to maintain as free ventilation of the 
accessory sinuses as possible. The acute sinusitis will heal in from 
ten to fourteen days. 

Suppose, in spite of these measures, while the general nasal 
inflammation subsided, the condition in the sinus showed no signs 
of abatement. General treatment is now no longer of avail; some¬ 
thing more radical is clearly indicated. The pathological con¬ 
dition is as follows: Nasal mucosa normal, with the exception of 
those portions bordering on the hiatus semilunaris; the fron¬ 
tal sinus mucosa acutely inflamed. This condition will rarely 


FRONTAL SINUS. 


233 


occur unless some interference with the drainage has taken place; 
therefore, it is clearly indicated that these passages be made 
more patulous with the prompt re-establishment of free drainage. 

We now have the choice of two courses: (1) infraction of the 
middle turbinate; (2) high resection of the anterior end of the 
middle turbinate. In making this choice we must at first con¬ 
sider the anatomical configuration of the nose, for, should the 
space between the septum and the middle turbinate be narrow, 
sufficient room cannot be obtained by infraction. The urgency 
of the symptoms must also be taken into account, for it may not 
be well to consider a probability (sufficient drainage after infrac¬ 
tion) when a certainty (sufficient drainage after resection occurs 



in about 95 per cent.) can be employed. Supposing, however, 
everything appeared favorable for healing after infraction. How 
should this procedure be accomplished! 

Technique of Infraction of the Middle Turbinate.— 1 . With 
twenty per cent, cocaine-adrenalin solution shrink thoroughly the 
anterior end of the inferior turbinate and anaesthetize anterior 
portion of the middle turbinate and septum, introducing the 
pledget of cotton between the processus uncinatus and the middle 
turbinate as far as possible without using force. Wait five min¬ 
utes, then bend the applicator and cocainize thoroughly as much 
of the processus uncinatus and hiatus semilunaris as possible. 

2. When anaesthesia is complete (ten minutes), introduce the 
Thompson scissors (Fig. 133), one blade directly beneath the 
anterior attachment of the middle turbinate as far as they can 
be pushed without meeting firm obstruction, and, holding them 





234 


THE ACCESSORY SINUSES OF THE NOSE. 


in as vertical a position as possible, sever the turbinate from its 
attachment. (Fig. 134.) (In wide nares this step may be omitted.) 

No bleeding follows this procedure, and unless one uses great force it is im¬ 
possible to wound the lamina cribrosa, because one must penetrate the entire anterior 
ethmoidal labyrinth from below upward with the external blade before the internal 
can reach this structure. 

3. Introduce a blunt submucous elevator between the processus 
uncinatus and middle turbinate and press the latter forcibly to¬ 
ward the septum (Fig. 135); a slight cracking noise will indicate 
that the turbinate has been fractured at its attachment. 

4. Ascertain if frontal sinus is accessible to the sound, and, if 
so, in what position the sound must be bent. 



Fig. 134.—Severing the middle 
turbinate at its anterior attach¬ 
ment to the lateral nasal wall. 




Fig. 135.—Infracting the mid¬ 
dle turbinate with a blunt ele¬ 
vator. 


Fig. 136.—Position of snare 
in removing the anterior por¬ 
tion of the middle turbinate. 
Note the proximity of the 
shank of the instrument to 
the cribriform plate. 


5. Introduce cannula bent in a corresponding manner to the 
sound, and wash out sinus with a warm boric acid solution. 

The advantages of this method over resection of the anterior 
end are: 

a. Lessened danger of infection. 

b. Requires much less time. 

c. The ethmoid cells are not opened. 

d. Little or no postoperative swelling, with its attending 

dangers. 

Contra-indicated when great polypoid changes have occurred 
in the region of the ductus nasofrontalis and hiatus semilunaris. 

In the majority of cases this will suffice to allow sufficient venti¬ 
lation of the sinus cavity to insure resolution. If, on account of the 
viscidity of the secretion, none has escaped, the expulsion may be 



FRONTAL SINUS. 


23 5 


facilitated by applying politzerization, as suggested by Hartman, 392 
thereby driving it, by the sudden compression of air, from the 
cavity. 

Healing may be accelerated by shrinking and lavage, at first 
daily, gradually reducing the treatments until entire recovery has 
taken place. If for any reason this procedure is contra-indicated, 
such as high deviation of the septum toward the affected side, or 
good results have not followed its application, resection of the mid¬ 
dle turbinate is required. 

Technique oe Resection of Anterior Third of Middle Tur¬ 
binate.— 1 . Cocaine as before. 

2. Use scissors as in infraction. 

3. Introduce snare, the loop bent slightly downward, and work 
the end of the instrument well upward until it is firmly in position 
at the superior extremity of the cut in the middle turbinate. (Fig. 
136.) 

If a deviation of the nasal septum exists that makes the introduction of the 
snare difficult, a high submucous resection is absolutely indicated, not only to allow 
one free access with the necessary instruments, but to remove an obstruction which 
probably is one of the causative factors of the sinusitis. 

Firm pressure is now applied to the handle of the snare, gradu¬ 
ally tightening it until very firm resistance is felt, when it will be 
necessary to use both hands in order to obtain sufficient pressure. 
If the sliding arm meets the base and the loop is still entangled in 
the nose, it will be necessary to unscrew the catch on the shank, 
make it shorter, and again apply pressure. 

Care should be taken, in preparing the snare, to see that the loop dis¬ 
appears well into the barrel, when the sliding arm reaches the base. If this has 
been done, we shall experience no difficulties in severing the turbinate at the first 
attempt. 

A sudden jerk will announce that the turbinate has been severed. 
Examination with the speculum shows the severed portion lying 
loose in the nose. This is removed with the fine-tooth forceps, 
otherwise it might be pushed far back into the nasal chambers, 
necessitating a search, which causes more or less delay. The nasal 
cavity is gently washed out with a sterilized normal salt solution 
in order to clear away the blood. Any shreds are removed with 
cutting forceps, such as those of Hartman. (Fig. 137.) 

392. Hartman: Ueber das Empyem der Stirnhohlen. Deutsch. Arch. f. klin. Med., 
Bd. 20 ; S. 531, 1871. 



236 


THE ACCESSORY SINUSES OF THE NOSE. 


An attempt is now made to introduce the flexible sound into the sinus. If the 
first attempt does not succeed, the instrument must be bent corresponding to the 
configuration of the nasofrontal passage and again introduced. 

This manoeuvre succeeds in 95 per cent, of cases, for, as Hajek pointed out, the 
obstruction does not lie in the mucosa of this passage, but rather in the general 
swelling of the nose, therefore, when this has been overcome by resecting the swollen 
anterior end of the middle turbinate, the principal obstruction has been removed. 

After a sound has been passed into the sinus, the cannula is introduced, a 
syringe fitted into place, and the cavity gently irrigated. This procedure should be 
repeated daily until pus is no longer observed. Careful manipulation with the 
cannula is necessary to prevent needless irritation of the mucosa, thus causing 
secondary swelling. If such a condition unavoidably arises, the irrigations can be 
discontinued for a day or two, but if symptoms of stagnation appear it will be 
necessary to enlarge the drainage passages, preferably with a rasp (see p. 260). 

This form of treatment practically never fails in acute frontal 
sinus inflammation. A conservative estimate of the cases cured 
by this method may be placed at ninety-five per cent., it being under¬ 



stood that the disease has been taken in its early stages before 
pathological changes have occurred in the mucosa or bone. 

Cases have been reported in which it was necessary to make a small external 
opening in the anterior sinus wall in order to relieve the symptoms, but this was 
in the days before the intranasal methods had reached that stage of. perfection to 
which they have at present attained. Any form of radical operation is strongly 
contra-indicated, as osteomyelitis and meningitis are especially prone to follow. 

Complications. 

The treatment of complications ensuing during the course of 
acute frontal sinusitis will depend largely upon the particular 
nature of the complication. They may be occasioned by two sep¬ 
arate pathological conditions or a combination of both, namely: 
1. From obstruction to drainage, with consequent stagnation 






FRONTAL SINUS. 


237 


(rare). 2. From an especial virulence of the infecting germ. 
The first condition, unless neglected, will be relieved by simple 
evacuation of the purulent scretion, either through the nose or 
externally by means of a small trephination in the anterior wall 
of the sinus. The second, however, will demand prompt and ener¬ 
getic treatment by means of a more or less radical operation, 
depending upon the amount of tissue involved. As it is often 
impossible to differentiate these conditions, it is wise, under such 
circumstances, to make a simple opening in the anterior wall and 
thoroughly flush out the sinus cavity. If improvement does not 
follow in a few hours, the entire wall, with as much neighboring 
tissue as is deemed proper, should be immediately removed so as 
to eliminate the original focus of infection, and the parts treated by 
the open method. 

CHRONIC INFLAMMATION: AETIOLOGY. 

Chronic disease of this* sinus does not arise idiopathically, as 
is sometimes the case with the maxillary, but results always as 
a sequela of an acute inflammation. 

The one great causative factor of chronicity is disturb¬ 
ance of the normal mechanism of drainage. This is not usually 
dependent upon one certain individual condition, but rather upon 
a variety of causes, such as deviation of the septum toward an 
affected side, thereby causing the middle turbinate to lie close 
to the lateral nasal wall; inflammatory swellings in the middle 
nasal passage, hypertrophies of the middle turbinate, polyp for¬ 
mations—in short, any condition, pathological or otherwise, which 
tends to obstruct or arrest the free flow of secretion from the 
acutely or subacutely inflamed sinus. 

When we recall to mind the long, narrow osseous passage (hiatus semilunaris) 
which forms the sole outlet from the frontal sinus, and how readily any of the 
above conditions might cause partial or complete obstruction to the outflow of 
secretion from this cavity, it is small wonder that the ultimate results are those 
of permanent tissue changes in the mucosa of the sinus. 

It is not necessary that this occlusion be either complete or 
continuous, as is well shown by the cases of chronic sinusitis fol¬ 
lowing repeated attacks of acute inflammation. 

This is not due to the severity of the inflammation so much 
as to the irritation. After the first attack the sinus mucosa does 
not fully regenerate before another acute attack supervenes. The 


238 


THE ACCESSORY SINUSES OF THE NOSE. 


reaction is now greater than in the original attack; regenera¬ 
tion occurs more slowly. The repetition of this process over and 
over again will eventually cause pathological changes (hyper¬ 
plastic degenerations, cyst formations, etc.) to take place not 
only in the mucous membrane of the sinus but in the drainage 
passages as well; while these conditions, moreover, in turn tend 
to further aggravate the disease. This process is well exemplified 
by those patients who are habitually subject to attacks of acute 
coryza. 

RETENTION OF SECRETION WITHIN THE SINUS. 

Too much stress has perhaps been laid upon this alone being 
a dominant causative factor of the chronicity. Retention of the 
secretion alone certainly cannot be responsible for the disease 
becoming chronic, as is proved by the maxillary sinus acting as 
a reservoir for pus from the frontal for months and even years, 
and, after one irrigation, remaining subsequently free from any 
pathological secretion. 

Killian’s 393 assumption that individuals suffering from max¬ 
illary empyema whose occcupations compel them to work with 
head low, acquire frontal sinusitis from the secretion flowing 
from the maxillary into the frontal, seems to require corrobora¬ 
tion. While the retention of the secretion alone may not result 
m chronicity, this condition, coupled with pressure within the 
sinus cavity, is a most potent factor for the formation of severe 
pathological disturbances. 

This pressure may be brought about in two ways: (1) positive; 
(2) negative. 

1. Positive pressure is caused by the complete contact of the 
pathological secretion on the mucous lining of the sinus. For this 
to occur some obstruction to its free outflow is necessary. The 
inflammatory products, being continually secreted, soon fill the 
sinus cavity, and when the cavity is filled secretion does not 
cease, but continues with even greater vigor, because of the 
added irritation. 

This is the condition which gives us such stormy symptoms and leads quickly 
to orbital and cerebral complications. 

Fortunately, complete permanent occlusion rarely occurs, as 
in the event of stagnation under pressure the drainage passages 


393. Killian (351), S. 1120. 



FRONTAL SINUS. 


239 


seem to act in the capacity of a safety valve, allowing the secre¬ 
tion to escape in jets and spurts. 

2. Negative pressure results from the absorption by the blood 
of the air normally contained in the sinus after the closure of the 
ostium. (See General ^Etiology.) If the sinus mucosa were in 
the secretory stage of acute inflammation, and this condition 
supervened, both positive and negative pressure would befall 
simultaneously: positive, from the pressure of the contained 
secretion; negative, from the vacuous suction in that part of the sinus 
containing air. The outcome of this double inflammatory condition, 
if continued for any length of time, must result in acute and severe 
complications of the neighboring organs. In any event, the in¬ 
jurious effects to the sinus mucosa will be severe and lasting. 

PATHOLOGY. 

Catarrhal or Fibrous .—This condition is the result of 
numerous inflammatory attacks which may or may not have been 
associated with a purulent discharge. It is a condition rather 
than an actual process, and represents an effort of the mucosa 
to check the advancement of the inflammation. While the mucous 
membrane lining of the sinus is thickened to 2-4 mm., it is not 
uniform, as the surface shows numerous irregularities. The 
epithelium is but slightly changed, and round-cell infiltration is 
sparse except in certain areas. The greatest change appears in 
the sub-epithelial layers, which have become the seat of fibrous 
connective-tissue formation. This is particularly noticeable 
around the vessels and over the periosteum. The vessels 
themselves are dilated and walls thickened. (Plate 2.) 

Purulent .—The mucosa does not present a uniform typical 
appearance, owing to the various degrees of inflammation in dif¬ 
ferent portions of the sinus. The region of the ostium may show 
all the signs of an acute inflammatory process, while farther away 
the pathological changes may be fibrous in character, and at the 
extremities the mucosa can appear perfectly normal. As a rule, 
the purulent condition is intimately associated with fibrous 
changes which have occurred during the quiescence of the numer¬ 
ous attacks. In an ordinary case the mucosa is thickened, the 
surface being irregular, certain areas having the appearance of 


240 


THE ACCESSORY SINUSES OF THE NOSE. 


velvet, while others are unevenly swollen from regional polypoid 
hypertrophies. 

The color varies from deep red to a grayish translucency. In 
consistency it is extremely friable, as it tears easily under the for¬ 
ceps, although loosened from the bone. Erosions and ulcerations 
are not frequently seen, even in those areas which have been sub¬ 
jected to pressure. Masses of granulation tissue are common, par¬ 
ticularly in the neighborhood of the ostium. Although polypoid 
hypertrophies are common, true polyps are rare. 394 In old cases 
pigmentation of the mucosa in osteophytic formations is encoun¬ 
tered. Gangrenous inflammation of the mucosa has been reported 
by several observers 394a > 394b > 394c in which the membrane was 
softened, dark and more or less loosened from the underlying bone. 

Chamberlin ® 4d reported a most interesting case in which the frontal sinus was 
filled with polyps which had caused erosion of the cerebral wall with apparent pres¬ 
sure atrophy of the anterior cerebral lobe. Recovery occurred after a radical 
operation. 

The character of the secretion depends largely upon the exter- 
.nal influences, as well as upon the species of the infecting micro-or¬ 
ganisms, and gives us an indication of the pathological condition of 
the sinus mucosa. 

Microscopical .—As various stages of inflammation are present 
it will depend upon the portion of membrane examined as to the 
findings. In a well-marked case certain changes are constant. The 
mucosa is thickened, all layers being affected in contradistinction 
to the acute form. The ciliated columnar epithelium in many places 
shows metaplasia into the squamous type, a manifestation of the 
chronicity of the affection. 395 

Round-cell infiltration is marked immediately below the basal 
membrane and around the vessels and glands. The lamina of the 
vessels are dilated and the number of the glands apparently in¬ 
creased. The periosteum is decidedly thickened, and the bone in 
many places shows evidence of rarefaction and new formation, giv¬ 
ing the surface a roughened appearance. 


394. Knapp: PolypenundEitersammlunginderrechtenStirnhohle. Arch.f. Augenhk., 
Bd. 9, S. 452, 1880. 394a. Hosch: Unsere Erfolge der radikal operation des Sinus frontales. 
Zeitschr. f. Ohrenhk., S. 347, 1910. 394b. Marschik: Sinusitis frontales bilateralis acuta 
mit Gangran derSchleimhaut. Radikal operation Heilung. Monat. f. Ohrenhk., S. 1467, 
1912. 394c. Schlemmer: Uebereinen Fall von Panantritis acuta, etc. Monat. f. Ohrenhk., 
S. 1229, 1912. 394d. Chamberlin: Report of a case of nasal polypi involving the orbit, 
frontal sinus and anterior fossa of the skull. Laryngoscope, p. 982, 1913. 395. Oppikofer- 
Mikroskopische Untersuchung der Schleimhaut von 165 chronisch Eiternden Nebenhohlen 
der Nase. Arch. f. Lary., Bd. 21, S. 422, 1909. 



FRONTAL SINUS. 


241 


Symptoms. 

The symptoms of chronic inflammation of this sinus may vary 
from their total absence to those quite as marked as in the acute 
stadium. Therefore, they had best be considered as of two periods 
—those of quiescence and those of excitation. 

Pain.— In contradistinction to the acute process, all phases of 
pain may be absent. Cases have been reported in which great 
inflammatory changes take place in the sinus mucosa without the 
patient having ever complained of the slightest symptom of head¬ 
ache. 396-399 

The character of the headache may assume any of the innum¬ 
erable phases characteristic of pain, ranging from a slight sense of 
numbness on the affected side to a sickening, splitting cephalalgia, 
the greatest paroxysms being synchronous with the heart-beat such 
as are observed in cerebrospinal meningitis. The latter phase is only 
met with in acute exacerbations during periods of congestion from 
overindulgence of food and drink, especially alcohol, and after un¬ 
wonted mental exertion or during the prodrome of a pending com¬ 
plication. 

The headache seldom assumes any definite form, but is subject 
to the greatest vagaries, depending upon even the most trivial oc¬ 
currences ; therefore, the sufferer must exercise certain prudences 
which are unknown to the healthy individual. Constipation, in¬ 
digestible foods, alcohol in every form, tobacco, mental and physi¬ 
cal exertion, stooping, jarring—in fact, any condition which 
tends toward circulatory congestion of the head—are prone to 
give rise to distressing symptoms and must be, therefore, strictly 
tabooed. 

Neuralgic pain in the chronic form is rarely observed, except in 
acute exacerbations of the inflammation from taking cold. 

Unquestionably, the character of the pain depends largely 
upon the drainage. If all conditions are favorable, little discom¬ 
fort is experienced; if certain obstructions supervene, the oppo¬ 
site will necessarily hold good. This statement is borne out by 
the instant relief often brought about by reinstating the patulous¬ 
ness of the drainage passages in these patients. 

396. Hajek (6), S. 180. 397. Luc: Empyeme latent du Sinus Frontale Operation, 
Guerison incomplete. Arch, internat. de Lary., No. 4, p. 216, 1893. 398. 390: Schech: 
Zur Diagnose u. Therapie der Chronischen Stirnhohleneiterung. Arch. f. Lary., Bd 3, 
S. 165, 1895. 399. Coffin: The Diagnosis of Frontal Sinus Disease. Trans. Am. Lary., 
Rhin. and Otol. Soc., p. 158, 1902. 

16 



242 THE ACCESSORY SINUSES OF THE NOSE. 

Location .—The affected area is above the orbit in the general 
region of the frontal sinns. (See Fig. 31.) The precise locality 
often changes with the character ; thus during the relative quies¬ 
cence the cephalalgia is apt to be indefinitely distributed over a 
larger region than when severe exacerbations occur. In the latter 
event the pain frequently concentrates in a definite area, mani¬ 
festing dissimilar characteristics. 

Diffuse headache is decidedly uncommon in chronic frontal sinusitis. According 
to our experiences, the appearance of this form during the course of this disease is an 
indication of the co-affection of one or more of the other sinuses. 

Typical pain located in the frontal sinus may finally be 
elicited during some stage of the affection. While this may not 
always be confined to the limits of the affected cavity, neverthe¬ 
less, the approximation is sufficient to warrant the appellation; 
the patients complain that the pain always takes its origin in the 
sinus. The prominence of this symptom is in direct ratio to the 
pressure within the cavity (both positive and negative). Occa¬ 
sionally the pain is greater in the healthy sinus. No other ex¬ 
planation than that of reflex phenomena can be given to this 
curious phase. 

Constancy .—As mentioned before, the pain shows a decided 
tendency toward instability. In a long and chronic case there is 
a well-defined tendency toward periodical exacerbation at certain 
hours of the day, followed by an equal regularity of remission. 
This exacerbation usually occurs during one of the morning 
hours, lasting a variable length of time and remitting as quickly 
as it appeared. The regularity with which this occurs day after 
day and week after week is quite inexplicable. 

Tenderness on Pressure.— As observed above, this symp¬ 
tom is prominent during the acute stage of frontal sinusitis. As 
the disease becomes chronic the tenderness subsides and not in¬ 
frequently disappears. Above the inner angle of the eye, how¬ 
ever, at that spot of greatest intensity in the quiescent stage, a 
certain amount may be elicited. One is often obliged to examine 
both sinuses simultaneously to obtain this result, and even under 
these conditions the test is rather uncertain. Only in those cases 
where severe inflammatory changes have occurred in the mucosa 
on the sinus floor, or where the osseous wall is abnormally thin, 
does one procure signs which are unmistakable in their evidence. 

The anterior wall of the sinus is, as a rule, insensible to pres- 


FRONTAL SINUS. 


243 


sure. During an acute exacerbation, or when the osseous struct¬ 
ure is affected, tenderness is sometimes observed, but, on the whole, 
this wall responds more quickly to percussion than to a steady 
pressure. It must, however, be borne in mind the degree of tender¬ 
ness may show great variations in the same case. During acute 
exacerbations it may be marked, while in the quiescent stage it may 
diminish almost to the point of disappearance. 

OEDEMA OF UPPER EYELID. 

An evanescent oedema frequently occurs in this locality, espe¬ 
cially soon after arising in the morning, and disappears during the 
day. It is caused by pressure within the sinus on the veins of the 
mucosa, which freely anastomose with those of the eye and eyelid. 

SECRETION. 

The discharge in chronic frontal sinusitis varies in consistency 
from a thin, serous, watery secretion 400 to a thick, inspissated, 
purulent outflow. It is not distinguished by one characteristic dur¬ 
ing the entire course of the disease, but changes under different con¬ 
ditions; thus, during the quiescent stage it may remain mucoid; if 
for any reason an acute exacerbation occurs it will become profuse, 
mucopurulent, or purulent, and remain so until the temporary acute 
symptoms abate, when it will again reassume its original mucoid 
consistency. In contradistinction to that emanating from the max¬ 
illary sinus, it is usually inodorous and almost never reaches the 
extreme foetidity of the latter. This thin, watery secretion between 
the outflow of the purulent material is due to hypersecretion of the 
mucoid glands from approximation of the mucous surfaces oc¬ 
casioned by the swelling. 

The explanation of this lies in the fact that the frontal sinus during’ the 
erect posture lies in the most favorable situation for drainage, the opposite being 
the case with the maxillary. In the latter decomposition takes place in the lowest 
depths of the secretion, which is the last to drain through the ostium. Unless 
artificially removed there remains always a residual stratum of purulent material 
which, teeming with saphrophytes, occasions the marked foetidity. This cannot occur 
with the frontal sinus, because the ostium is situated at the lowest portion, and, 
should stagnation with saprophytic infection occur, the fetid pus will be the first 
to drain out as soon as patulosity of the drainage channels is again established. 
A certain amount of putrefaction may occur in the depths of the finger-like pro¬ 
jections or behind partial septa which occur in large sinuses. One thorough 
lavage, however, is usually sufficient to remedy this defect unless caries or necrosis 
has set in. 


400. Wertheim: Beitrag z. Pathol, u. Klinik der Erkrank d. Nasennebenhohlen. 
Arch. f. Laryn., Bd. 11, S. 169, 1901. 



244 THE ACCESSORY SINUSES OF THE NOSE. 

The amount secreted during the day depends upon the size 
of the sinus, as well as upon the severity of the disease. The 
discharge is not usually constant, but shows a tendency to period¬ 
ically empty itself. It should not be inferred, however, that 
during certain portions of the day large amounts of secretion are 
thrown off, the remaining time being free from any traces. On 
the contrary, a continual ooze is always present so long as the 
ostium remains sufficiently patulous to transmit the purulent 
products. 

When the secretion is scanty it shows a decided tendency toward crusting. 
These crusts are small and light in color and do not resemble those found 
associated with atrophic rhinitis. 

The hours of the forenoon seem to be the usual time for the 
bulk of the discharge to exude, on account of the amount which 
had collected during the night; this is best judged by the quan¬ 
tity of handkerchiefs used by the patients at this time. Natu¬ 
rally, if other sinuses are coaffected, the amount of the discharge 
will be increased. The greater the area of diseased mucosa, the 
larger the amount of purulent products secreted. 

PLACE OF APPEARANCE OF SECRETION. 

Normally, one would expect to find the secretion exuding from 
beneath the anterior end of the middle turbinate. In favorable 
cases this will occur, but many changes have usually taken place 
in the nasal mucosa, so that we often find it directed elsewhere. 
A swollen middle turbinate may guide it to the olfactory fissure 
by capillary attraction. If the uncinate process is swollen (which 
is usually the case), the secretion is directed backward over the 
posterior portion of the inferior turbinate. Polyps in the middle 
nasal passage may also divert its flow from the natural channels. 
All of these contingencies must be considered, and, so far as pos¬ 
sible, eliminated, before one is able to follow the flow to its nat¬ 
ural origin. 

DISTURBANCES IN OLFACTION. 

Anosmia and occasionally cacosmia seem to be prevailing feat¬ 
ures in this form of nervous disturbance. Similar to the anosmia 
occurring during the acute form, it may find its origin in the 
occlusion of the olfactory space by the swollen middle turbinate. 
In this condition the sense of smell is present, but is prevented 


FRONTAL SINUS. 


245 


from performing its function by the inability of odorous sub¬ 
stances to reach the terminal filaments. 

The second form is caused by purulent secretion being drawn 
into the olfactory fissure by capillary attraction and being dis¬ 
seminated over the area of olfaction. Power of olfaction is also 
present in this condition, but is subjugated by the thin layer of 
secretion, which prevents odorous particles from coming into 
actual contact with nerve-endings. 

It is probable that the constant contact of purulent secretion with the cells 
of olfaction eventually causes them to undergo some form of degeneration and 
ultimately lose their function. To bear out this hypothesis one need but cite the 
numerous cases which, after complete recovery from their sinus affection, never 
regain the power of olfaction on the affected side. 

The subjective appreciation of offensive odors is occasionally 
complained of by patients suffering from chronic inflammation of 
the frontal sinus. It would seem that no perversion of function is 
present with these individuals, as they really perceived something 
that existed, namely, an actual fetid odor within the nose. Nat¬ 
urally, changes of putrefaction must exist before this symptom 
can occur, although the secretion itself may be perfectly free 
from odor. 


APPEAKANCE OF THE NOSE. 

Externally little is seen, with the possible exception of ecze¬ 
matous eruptions around the alae. 

Rhinoscopy— 1 . Secretion: In addition to what has been said, 
it might be well to add that during the quiescent period the dis¬ 
charge is thin and glairy, giving a varnished appearance to the 
structures over which it flows. During the active purulent stage 
it is not unlike that seen in the acute stadium. 

2. While changes in the mucosa are to be observed, they are 
not, at first glance, as apparent as those occurring in the acute 
stadium. In the former, the changes are more of a fibrous nature, 
with permanent tissue changes; in the latter, active hypenemia 
forms the bulk of the hyperplasia. Unilateral obstruction of the 
nares is generally present to a greater or lesser degree. When 
we consider that partial stenosis was, in all probability, originally 
present, only a slight accentuation of this condition would be suffi¬ 
cient to make a marked contraction on that side. 

The obstruction is occasioned by a number of causes. 


246 


THE ACCESSORY SINUSES OF THE NOSE. 


1. Hypertrophy of the (a) uncinate process; (b) middle tur¬ 
binate; (c) tuberculum septi. 

2. Formation of true polypoid growths (mucous polyps). 

It will be noted that the hypertrophies and polyp formations always occur 
in the tract of the exudate. The irritation produced by being constantly saturated 
with this purulent material undoubtedly predisposes to, if not actually causes, 
these structural changes. 

(a) Hypertrophy of the uncinate process occurs so frequently 
in cases which have run a chronic course that it has been de¬ 
scribed as typical for this affection. 401 By anterior rhinoscopy 
this structure is unduly prominent and takes on a grayish-white, 
cedematous color. In later stages true polyp formation takes its 
origin at this point. 

(b) The anterior extremity of the middle turbinate is also fre¬ 
quently hyper plastically enlarged. In the beginning it is dotted, 
having a sort of salt-and-pepper effect. Later, as cedematous 
infiltration occurs, the appearance is more like that of the inferior 
surface of a mucous polyp. 

( c ) Hypertrophy of the tuberculum septi: 402 This occurs 
directly opposite the anterior end of the middle turbinate, and 
appears to follow sinus empyema, in which the inflammatory prod¬ 
ucts flow over that portion of the septum. It is not typical for 
frontal sinus disease, but may occur with any purulent inflamma¬ 
tion of the sinuses of the first series. 

APPEARANCES OF THE THROAT. 

Sclerotic changes are always present, sometimes being atrophic, 
sometimes assuming the granular form. Unilateral pharyngitis 
on the affected side is pathognomonic of chronic sinus disease. 

DIZZINESS AND VERTIGO. 

These are associated, usually, with the frontal 402a and sphenoid 
sinuses. No especial reason can be attributed to their appearance, 
unless it is due to some circulatory phenomena. They are, however, 
not necessarily significant of cerebral involvement. 

401. Kaufmann (104), Mon. f. Ohrenhk., No. 24, S. 13, 1890. 402. Schaffer: Zur 
Diagnose u. Therapie d. Nebenhohlen d. Nase, etc. Deutsch. med. Woch., Bd. 16, S. 
905, 1890. 402a. Hurd: Observations on Some Unusual Cases of Frontal Sinusitis. 
Laryngoscope, p. 611, 1909. 



FRONTAL SINUS. 


247 


DIAGNOSIS . 399 403 

The diagnosis of chronic frontal sinusitis is often one of the 
most difficult problems facing the rhinologist. During the quies¬ 
cent stage of disease (latent empyema) it is often impossible to 
discover any symptom of pathologic import which points directly 
to this sinus. A diagnostic needle puncture is out of the ques¬ 
tion, and one often hesitates to sacrifice a portion of the middle 
turbinate for diagnostic pjirposes alone. Absolutely no reliance 
can be placed on the value of the patient’s statements regarding 
the origin of the secretion, as he may state it forms in the naso¬ 
pharynx. Our first duty in problematical cases is to make re¬ 
peated examinations until all doubt as to the actual existence of 
sinus disease is dispelled. For this purpose, if needs be, all diag¬ 
nostic agents at our hand should be employed (suction, trans¬ 
illumination and X-ray). When convinced that a sinus disease 
is actually present, even though the symptoms point toward the 
frontal sinus, the maxillary should be punctured and irrigated. 

This may seem a needless procedure, but I have frequently found pus in 
the antrum and even a true inflammation of the mucosa by this method, whose 
existence had never been suspected. 

If the antrum is found healthy, no harm has been done, and 
we have eliminated one source of the suppuration. Attention 
must now be directed towards introducing a sound and subse¬ 
quently a cannula into the frontal sinus. Presupposing that an 
attempt had already been made and had failed, we must either 
infract or excise a portion of the middle turbinate. 

Too much emphasis cannot be placed upon the maxim that the absence of 
secretion proves nothing. Only the actual presence of pus is of positive diagnostic 
worth. 

Supposing, however, we have discovered secretion oozing 
from the anterior superior portion of the hiatus semilunaris after 
infraction, our first thought is to ascertain as far as possible its 
exact source. To definitely state that the frontal sinus is dis¬ 
eased without coaffection of one or more of the anterior group 
of ethmoidal cells is out of the question, particularly when one 
takes the so-called orbital ethmoidal cells into reckoning.* * 


403. V. Eicken: Zur Diagnose der Stirnhohlenerkrankungen. Verh. siiddeut. Lary., 
S. 56, 1906. 

* Coakley says he has never seen a case of frontal sinusitis in which some of the ethmoid 
cells did not share in the disease. 



248 


THE ACCESSORY SINUSES OF THE NOSE. 


Should polyps and hypertrophies further obstruct the view it is indicated 
that all structures that offer any bar to the free access to the sinus be removed. 
This is particularly applicable when they obstruct the passage of the sound. 

Unilateral hyperaemia of the uncinate process and operculum 
of the middle turbinate, even in the complete absence of pus, is 
very suggestive of inflammation of the frontal and anterior eth¬ 
moidal cells. If pus is seen, we must follow it to its source in 
order to make a positive diagnosis. So far as the frontal sinus 
is concerned, this can only be done by means of the sound and 
cannula, because the ostium lies so far forward in the hiatus semi¬ 
lunaris that to judge without using these instruments whether 
the secretion comes from the frontal ostium or from the ethmoid 
cells is almost impossible. 

Fortunately this is often of little moment, as the connection between the 
anterior ethmoid labyrinth and frontal sinus is so intimate that these structures 
are usually coaffected. 

Our next step is to introduce a sound, followed by a catheter, 
and forcibly inject air into the sinus in order to expel the con- 

- 

Fig. 138.—Cannula for irrigation of the frontal sinus. 

tained secretion. After the sound has been introduced (see In¬ 
troduction of Sound) we note carefully if a flow of secretion 
immediately follows its removal. In any case, the cannula (Fig. 
138) is bent corresponding to the curve of the sound and intro¬ 
duced in like manner. 

Although the cannula is but slightly larger than the sound, considerable difficulty 
is often encountered before it finally is brought into the sinus. This is due in 
great measure to the sharp extremity catching in the swollen mucosa. The only 
remedy for this is to exercise the greatest patience with the least possible degree 
of force, for the slightest traumatism will often defeat our purpose. 

After the introduction of the cannula has been accomplished 
the nib is forced in the end and locked by turning. The syringe is 
filled with air and the latter forcibly injected into the sinus cavity. 

This procedure, while apparently harmless, has given rise to most alarming 
symptoms. Bruhl 404 reports a case of temporary blindness lasting twenty-four 
hours, immediately following this manoeuvre. 


404. Bruhl: Zur Kasuistik der Stirnhohleneiterungen. Zeitschrift f LarvneoWip 
Bd. 1, S. 637, 1909. . 6 * * 







FRONTAL SINUS. 


249 


Should secretion be blown out of the ostium, our diagnosis, so 
far as the frontal sinus is concerned, is made; the question now 
arises, what is the extent and severity of the inflammation? The 
possibility of several conditions must be borne in mind. 1. The 
sinus mucosa may be actively inflamed and constantly secreting and 
exuding thick pus. 2. Fibrous degeneration may have occurred in 
portions of the mucosa; as a consequence, the secretion is thin and 
serous. 3. The mucosa may be so swollen as to almost obliterate the 
lumen of the sinus with little or no secretion. 4. The inflamma¬ 
tion may have disappeared, leaving only a residue in the recesses. 

As only a certain amount of the 
contained pus will be expelled by this 
method, it will be necessary to irrigate 
the cavity with a mild sterile fluid, 
preferably a warm, normal salt solu¬ 
tion. The pressure in the beginning 
must be very light, otherwise consider¬ 
able distress may be occasioned the pa¬ 
tient. The rubber tube connecting the 
syringe with the cannula must also be 
held in a certain position (Fig. 139) to 
avoid soiling not only the garments of 
the patient but the operator as well. If the mucosa of the sinus is 
diseased, some trace will invariably present itself in the returning 
liquid. 



Fig. 139.—Position of the hands in irrigat¬ 
ing the frontal sinus. 


One is in a position to judge, with an approximate degree of accuracy, the 1 
quantity and quality of the inflammatory exudate, an important point when 
taken into consideration with the symptoms. If the secretion is always scanty, 
yet the symptoms remain severe and apparently little influenced by the irrigation, 
we can be sure permanent pathological changes have occurred in the cavity. If, on 
the other hand, a considerable amount of fresh purulent material is invariably 
brought to light with the escape of the injected fluid, with immediate alleviation of 
the symptoms, the disease has probably not affected the deeper layers of the sinus 
mucosa. This does not invariably hold good, but in our experience is the rule rather 
than the exception. 

Some little criterion of the severity of the disease can be formed by the char¬ 
acter of the secretion. If it is thick, inodorous and of like consistency (what the 
older writers termed laudable pus) the mucosa alone is affected, without stagnation, 
for no disintegration of the secretion has taken place. This form is generally in¬ 
dicative of a general catarrhal inflammation of the sinus mucosa. 

A curdy secretion which separates into broken-down masses in the irrigation 
liquid signifies an old chronic condition with deep-seated inflammation coupled with 
considerable tissue changes. Foul-smelling pus is the result of saphrophytic infection 
and is of greater significance in the frontal than in the maxillary sinus, as in the 
former the sympathetic affection of the bony walls is to be suspected. 



250 


THE ACCESSORY SINUSES OF THE NOSE. 


A small amount of secretion appearing after lavage does not 
necessarily imply that the disease is not extensive, for the mucosa 
may be so swollen as to almost obliterate the sinus cavity. Partial 
septa may also be present, dividing the sinus into a number of fossae 
which communicate with one another by such narrow orifices that 
the fluid cannot reach the various interstices. If the injected 
liquid partially returns from the opposite nostril, a perforation has 
occurred in the partition between the two frontal sinuses, with a 
communication of the disease to the opposite side. 405 

This appearance of small amount of discharge, is also true if the 
anterior ethmoid cells are diseased. How, then, shall we dif¬ 
ferentiate these two conditions! This is often impossible, at least 
for the moment. If the discharge is profuse, by allowing the 
patient to wait for thirty to sixty minutes after the lavage and again 
making an examination, if the secretion is again seen, even in small 
quantity, it must have issued from the ethmoid cells, for it is not at 
all reasonable to suppose that the mucosa of the frontal sinus could 
secrete an appreciable quantity of pus in such a short interval 
of time. 

In order to determine whether the secretion comes from the 
frontal sinus or anterior ethmoid cells it has been advised to insert 
a tight-fitting cotton plug into the nasofrontal passage (hiatus semi¬ 
lunaris) above the ostiums of the ethmoid cells. This is allowed to 
remain over night and removed the following morning. If the 
frontal sinus is not secreting, no pus will appear after the removal 
of the cotton, and vice versa . 

I do not look with particular favor oil this procedure by reason of the in¬ 
convenience, not to say discomfort, suffered by the patient due to the damming* 
back with stagnation under pressure of the secretion. The pledget of cotton, more¬ 
over, may leak, thus furthering the difficulties of diagnosis. 

If, despite our best efforts, catheterization, for any reason, is 
impossible to accomplish, and the symptoms are such that it is im¬ 
perative an accurate diagnosis be made, there remains but one 
procedure—an external exploratory opening in the supra-orbital 
region. 

EXTEEXAL SYMPTOMS. 

Tenderness on pressure at the junction of the inferior and lateral 
walls is not nearly so common as in the acute form; however, when 
distinctly present, it is a symptom of great diagnostic importance. 

405. Killian (340), S. 962. Ueber communicirende Stimhohlen. Miinch. med. Woch., 
Bd. 44, S. 952, 1897. 



FRONTAL SINUS. 


251 


DILATATION OF ANTERIOR WALL AND FISTULA FORMATION. 

Bulging of the sinus walls occurs usually in connection with a 
mucocele or tumor; when associated with chronic empyema it must 
be of years * duration. The following are the pathological 
changes. 406 The osseous substance of the inner surface of the sinus 
wall gives way to the constant pressure and atrophies. The phys¬ 
iological formation of new bone on the external surface continues 
undisturbed, owing to the external periosteum being unaffected by 
the pressure. In this manner there occurs an excentric dilatation. 
As the condition progresses the atrophic process gains the upper 
hand; the new bone formation ceases entirely, and the sinus wall be¬ 
comes as thin as paper. During this stage the parchment-like crack¬ 
ling is elicited on pressure. Finally the wall loses all its bony 
substance, leaving a membranous fluctuating tumor. 

Perforation of any of the walls as a result of chronic suppura¬ 
tion is a rare condition and comparatively seldom met with. Most 
of the cases which have come under observation have been due to an 
unsuccessful external operation. The orbital wall is perhaps most 
frequently affected, and when rupture occurs it is directly below the 
inner extremity of the eyebrow, at that portion which contains the 
small foramina for the passage of the communicating veins. The 
anterior wall, when affected, usually shows the perforation above 
the inner end of the eyebrow. The posterior or cerebral wall is 
affected much less than the two preceding. This is due to the ex¬ 
ceptionally good nutrition furnished by the double layer of peri¬ 
osteum. 

The septal wall has been found the seat of perforation during 
operation, 406a which had previously not been suspected. In this man¬ 
ner a diseased sinus may affect a healthy one, causing a double 
frontal sinusitis. 


CAUSE OF THE FISTULA FORMATION. 

The perforation has its inception during an acute exacerbation 
of a chronic inflammation. A small area of the sinus mucosa, from 
pressure due to occlusion of the drainage passages, or especial 
virulence of the infective micro-organism, becomes necrotic with 
thrombophlebitis of the small veins which penetrate the bone. The 
infection is thus carried to the external periosteum of the sinus wall, 

406. Karbowski: Ein Kasuistischer Beitrag zur doppelseitigen Stirnhohlenerweiterung. 
Zeit. f. Laryn., Bd. 4, S. 553, 1911. 406a. Killian: Ueber kommunizierenden Stirnhohlen. 
Munich med. Wochenschr., 32, 1892. 



252 


THE ACCESSORY SINUSES OF THE NOSE. 


setting up an external purulent periostitis. The bone thus losing its 
nourishment softens and breaks down in this circumscribed area. 

The extent of the necrosis depends upon the pressure and the 
virulence of the infection. It may range from the size of a large 
needle to a considerable area of the sinus wall. Large necrotic 
sequestra may slough away, as has been reported. 40611 ’ 406c 

Fistula formation occurs also in tuberculosis and syphilis of the 
frontal plate. Whether connection with the sinus proper exists 
may be learned in the following ways: 1. Should communication 
exist, when the fistula is irrigated water will appear in the middle 
nasal passage. 2. If a sound be passed into the frontal sinus 
through the nose and another directly into the fistulous opening, 
they will meet one another. 

In all doubtful cases it is necessary to have the opinion of the 
oculist regarding the ophthalmic conditions. Very often impending 
complications may be anticipated and thwarted through these 
examinations. 

ADJUNCTS TO DIAGNOSIS. 

Transillumination . 407 - 409 —This method was greatly in vogue in 
the early part of 1900. The rationale is to place double-hooded 
electric lamps 410 beneath the inferior floor of the sinus in a darkened 
room and, after applying the current, note the difference of light 
intensity over the anterior sinus walls. This was formerly con¬ 
sidered of great value in diagnosticating the comparative differ¬ 
ences in the pathological condition of the two sinuses. Unfortu¬ 
nately, subsequent observers 411-414 have demonstrated the fallacy 
of this opinion. 

It is supposed that either a collection of purulent material or 
swollen mucosa would act as a barrier to the passage of the rays of 
light. As a matter of fact, large transilluminatory areas in the 
supra-orbital region have been observed, yet on subsequent opera¬ 
tion the frontal sinus has been found to be the seat of a severe 
inflammation. This has also been noted where the margo-supra- 
orbitalis was thick and diploic and no sinus existed. Under these 
circumstances very little dependence evidently can be placed upon 

406b. Watson: Diseases of the Nose and its Cavities, p. 393. 406c. Sebileau: 

Sequestre frontal dans un cas de sinusite. Soc. de Chirurgie, Dec., 1913. 407. Vohsen: 
Berliner klin. Woch., Bd. 27, S. 274, 1890. 408. Claus: Zur Durchleuchtung der Stirn- 
hohlen. Arch. f. Lary., Bd. 13, S. 103, 1903. 409. Logan Turner: Accessory Sinuses of 
the Nose, p. 120, 1901. 410. (Double Lamp) Furet: Ann. d. mal de l'orielle, etc.. T. 25, 
p.692, 1899. 411. Ziem: On the Transillumination of the Maxillary Antrum. Journ. of 
Laryng., p. 284, 1903. 412. Zarnico: Lehrbuch, S. 178, 1910. 413. Onodi: Die Stirn- 
hohle (1200 skulls), S. 57-67, 1909. 414. Hajek (6), S. 200. 



FRONTAL SINUS. 


253 


this as a valuable consideration in diagnosing frontal sinus affec¬ 
tions; however, it is of some value as corroboratory evidence . 414 

Rontgen Ra?/. 415-418 —After much experimentation it was found 
that the X-ray offered considerable assistance in ascertaining not 
only the shape and size of the frontal sinus, hut whether disease 
existed either in the shape of purulent collections or in pathological 
changes in the lining mucosa. It was found that the best results 
were obtained by placing the forehead of the patient upon the photo¬ 
graphic plate and taking the picture in the posterior-anterior direc¬ 
tion . 419 On examining the plate it was shown that the contour of 
the diseased side appeared less sharp than that of the sound and cast 
a shadow corresponding to the intensity of the disease. The X-ray 
is of value for diagnostic purposes where great deviation of the 
nasal septum is present, thereby prohibiting any nasal examination. 


DIFFERENTIAL DIAGNOSIS. 420 


Certain conditions may simulate frontal sinus disease, such as 
certain forms of neuralgia and headache from Bright’s disease. 
Frontal Sinus Disease. Idiopathic Neuralgia. 


History of acute coryza. 

Pain at first mild, becoming severer. 
Little change in intensity. 

Pain intensified by pressure. 

Coughing and stooping intensify pain. 
Alcohol and tobacco intensify pain. 

In all doubtful cases the ui 
several times to make perfectly 


No such history. 

Pain sharp at onset. 

Pain paroxysmal with free intervals. 
Pain relieved by pressure. 

Muscular movements intensify pain. 

Not so. 

ine should he examined at least 
sure that no kidney lesion exists. 


Chronic Frontal Sinusitis. Mucocele . 401 

Any age after twenty years. Any age after 20. 
History of an acute attack. 

Subjective symptoms inter- No subjective symp- 
mittent. toms. 

Nasal discharge intermittent. No nasal discharge. 
Dilatation of sinus very rare. Always present. 

Examination of the nose shows: 

Changes in mucosa. No changes. 

Sounding of frontal sinus Sinus cannot be 
produces purulent secretion. sounded. 


Malignant Tumor. 

Past forty years of age. 

No history of acute stages. 
Subjective symptoms progres¬ 
sive. 

May be constant or absent. 
May or may not be present. 


No changes. 

Sinus impossible to sound 
when disease is located 
around ostium. 


415. Coakley: Frontal Sinusitis: Diagnosis, Treatment and Results. Annals of Otol., 
Lary. and Rhin., Sept., p.452,1905. 416. Mosher: The Use of the X-ray m Sinus Disease. 

Laryngoscope, p. 114, 1906. 417. Goldman and Killian: Beitrage zur khmschen Chirurgie, 

1907. 418. Chisholm: Skiagraphy in the Diagnosis of Frontal Sinusitis. Annals ofOtol., 

Lary. and Rhin., p.979, Dec., 1906. 419. Beck's Atlas of Radiography, 1910. 420. Tilley: 

Some Points in the Differential Diagnosis of Chronic Suppurative Pansinusitis, with Discus¬ 
sion. Trans. 1st Internat. Lary .-Rhin. Congress, p. 214, 1908. 421. Valude: De la 
mucoc&le du sinus frontal. Annales d'oculistique, Dec., 1899. 




254 


THE ACCESSORY SINUSES OF THE NOSE. 


PROGNOSIS. 

In the strictest sense of the word the ultimate prognosis for 
chronic frontal sinusitis is good. It must not, however, be in¬ 
ferred that absolute healing, i.e., a return of the normal, invari¬ 
ably occurs; on the contrary, despite all therapy and operative 
procedures, frequently enough a more or less constant leakage 
often remains. The immediate prognosis after any form of treat¬ 
ment (the radical methods excepted) is, however, an exceedingly 
uncertain proposition. 

A patient presents himself suffering with an old case of 
chronic frontal sinusitis which has never been treated. We find 
hypertrophies occluding the drainage passages, with certain stag¬ 
nation of the secretion. Can we promise him a cure by intranasal 
procedures! Probably not. Although every indication points 
toward favorable results following such measures, nevertheless, 
certain tissue changes may have taken place in the mucosa of the 
sinus which preclude restitutio ad integrum. Improvement will 
undoubtedly take place up to a certain point, then the course of 
the disease will remain unchanged. Free drainage, while essen¬ 
tial in such cases, is not a panacea, as many disappointing expe¬ 
riences have taught us. 

During the long course of the disease, areas of degeneration 
of the mucosa from long-continued suppuration have occurred. 
No amount of ventilation or drainage will remedy this defect, as 
those diseased portions of the mucous membrane will continue to 
secrete so long as they are present. This fact explains the cause 
of failure in those intranasal operations which depend upon the 
installation of free drainage by enlarging the drainage passages. 

For this reason we must exercise the greatest circumspection 
in making prophecies after any form of conservative treatment 
in this disease. So far as the subjective symptoms are concerned 
(and, after all, these are the source of the patient’s complaints), 
much more can be promised. These depend largely upon the con¬ 
dition of ventilation and drainage. In those uncomplicated cases 
where absolutely unhindered drainage has been installed, the most 
distressing symptoms have invariably disappeared. 

The pain is always mitigated, discharge is greatly lessened, 
and, above all, those nervous and mental manifestations which 
are infinitely the bete noire of the entire symptom-complex rapidly 
disappear. The discharge resolves itself into thin, serous oozing. 


FRONTAL SINUS. 


255 


which may even cease entirely and the patient, to all intents and 
purposes, be cured. The first acute coryza, however, will cause 
the mucosa to again throw off a purulent exudate, which, during 
the natural course of the disease, again gradually diminishes and 
finally ceases. This cycle will continue ad infinitum , unless more 
radical measures are instituted.* Coakley 367 reports 14 per cent, 
cured by intranasal treatment, 51 per cent, improved, and 35 per 
cent, result unknown. 

So far as the patient is concerned it is a personal equation under the circum¬ 
stances whether he considers himself cured. Some individuals are but little annoyed 
by a more or less constant discharge from the nose with occasional headaches. 
Others brood over such a condition, and, by magnifying in their imagination their 
symptoms, remain dissatisfied until radical procedures have been adopted. 

When the bone has become affected or complications have super¬ 
vened, the establishment of drainage has little influence upon the 
course of the disease. The prognosis after a radical operation is 
exceedingly good, provided complications, particularly intracranial, 
have not occurred, for by this means it is possible to inspect all parts 
of the sinus cavity and remove those portions which appear diseased 
and would protract the period of healing. 

TUBERCULOSIS. 

That this affection of the frontal sinus is very rare is proved by 
the fact that but nine cases have been reported, of which two have 
been recently added by Thomas. 421a These have invariably oc¬ 
curred in individuals who had tuberculosis of some other portion of 
their bodies. The infections usually ran a chronic course, requiring 
months and even years after the first symptoms referable to the 
frontal sinus appeared until a frontal fistula resulted. The perfo¬ 
ration of the sinus wall, however, usually occurred during an acute 
attack. Extensive disease of the surrounding bone is always pres¬ 
ent with degeneration of the sinus mucosa into a cheesy, necrotic 
mass. Only an extensive radical operation, thoroughly removing 
all diseased tissue, offers any hope for recovery. 

SYPHILIS. 

It is doubtful if a genuine non-gummatous case of syphilitic 
frontal sinusitis has ever been observed. The frontal bone, how¬ 
ever, is a seat of predilection for attack during the third sta ge of the 

* As a matter of fact, simple, uncomplicated cases of chronic frontal sinusitis rarely go on 

to r&dwdo Thomas: Tuberculosis of the Frontal Sinus. Journ. Am. Med. Asso., July 24, 
p. 308, 1915. 





256 


THE ACCESSORY SINUSES OF THE NOSE. 


disease. It is possible that this might be confused with a tubercular 
infection. Should such an uncertainty arise, the Wassermann and 
luetin tests will speedily establish the diagnosis. 

CHRONIC COMPLICATIONS. 42lb 

That the frontal sinus more often is the seat of complications 
than its fellow cavities is due to the following anatomical facts: 

1. It communicates with both the brain and the orbit in a much 
larger area. 

2. Intimate connection exists; between the veins and lymphatics 
of the sinus mucosa and those of the dura mater and meninges. 

3. The walls are frequently very thin and, indeed, often show 
dehiscences. 

4. It often contains numerous projections and fossa which allow 
the infecting micro-organisms to remain undisturbed, thus favoring 
their virulence and toxicity. 

5. The cerebral wall contains numerous small foramina for the 
transmission of veinlets through which micro-organisms can find 
entrance into the cranial cavity. 

The frequency with which complications follow chronic frontal sinusitus is un¬ 
certain, as precise statistics are practically unavailable. However, Gerber puts it at 
5 per cent., though admitting that his percentage is somewhat higher than other 
rhinologists. 

Complications occur much oftener in (a) older individuals, 
( b) in males, and ( c) on the left side. The larger the sinus the more 
predisposition toward this eventuality. 

POSSIBLE PATHS OF INFECTION. 

1. By direct continuity: Ulceration occurs in a given area on 
the sinus mucosa which communicates to the immediate underlying 
bone and results in the formation of a carious or necrotic spot. The 
inflammation continues through the bone, eventually causing some 
lesion in the neighboring part, depending upon the wall affected: if 
the orbital wall is diseased, subperiosteal abscess, periorbitis, peri¬ 
orbital abscess, or orbital phlegmon; if the posterior or meningeal 
wall, various forms of meningitis, sub- or intradural abscess. 


42 lb Gerber: Die Komplikationen der Stirnhohlenentztindungen. Berlin, 1909. 



FRONTAL SINUS. 


257 


2. Through congenital or acquired dehiscences: When a dehis¬ 
cence is present, the sinus mucosa lies in direct contact with the dura 
and perimeningeal structures; therefore, deep infection of the 
mucosa is practically equivalent to inflammation of the dura. 

3. Through the venous anastomosis (Fig. 140): The investiga¬ 
tions of Kuhnt 98 have shown that the veins of the frontal sinus 
communicate freely both with those of the orbit and of the brain. 
According to Zuckerkandl, 422 a direct communication also exists 
to the superior longitudinal sinus. 

4. Through the passages for the optic nerve and ophthalmic vein. 

5. Through the lymph-channels: Andre, 423 having made a 
special study of this subject, has conclusively demonstrated the 
lymphatic connection between the free meningeal spaces and the 
mucosa of the nose and frontal sinuses. Falcone 424 has also found 
a direct connection between the lymphatics of the mucosa of the 
frontal sinus and those of the subdural and subarachnoidal spaces. 
This was accomplished by injecting substances from the meninges 
which filled the lymphatic channels in the frontal sinus without 
entering those of the nasal mucous membrane. Of all these possi¬ 
bilities, the first, i.e., by direct continuity, is by far the most 
important. 

The actual complications may be divided into: 1. Those affect¬ 

ing the sinus itself. 2. The oculo-orbital. 3. The intracranial. 

Those affecting the sinus itself; changes in the bones: (a) 
Periostitis and subperiosteal abscess. These changes may affect 
any of the sinus walls, although the spot of predilection appears to 
be on the orbital partition. They are characterized by a point of 
exquisite tenderness appearing on the inferior wall near the inner 
angle of the eye. The upper lid is swollen and cedematous, some¬ 
times so inflamed as to completely close the eye. The pathological 
changes in the periosteum consist of a thickening, agglutination and 
discoloration; punctiform hemorrhages with thinning and softening 
of the underlying bone. These forms of complications appear more 
frequently associated with the acute form of frontal sinusitis. 

( b ) Caries and necrosis. These osseous affections appear 
mostly on the inferior and anterior walls and may range from the 
size of a needle puncture to ulceration of the entire wall. They 

422. Zuckerkandl (45), S. 356. 423. Andre: Recherches sur les lymphatiques du 
Nez et des Fosses Nasales. Ann. des mal. de Fondle, etc., T. 31, p. 425, 1905. 424. Falcone, 
quoted by Sieur and Rouvillois: Traitement chirurgical des antritis Frontales. Arch, 
inter, de Laryn., T. 32, p. 398, 1911. (Original in II Tommasi, No. 24, 1907.) 

17 



258 


THE ACCESSORY SINUSES OF THE NOSE. 


are usually due to occlusion of the drainage passages either 
through an acute coryza or polypoid changes. Influenza and the 
infectious diseases (scarlet fever, diphtheria, measles, and ery¬ 
sipelas) also appear to play an important causative role. In 
contradistinction to periostitis and ostitis, caries and necrosis 
appear most frequently associated with chronic frontal sinusitis. 
The symptoms of these affections are similar to those of periostitis, 
except greatly intensified, particularly the headache. Occasion¬ 
ally this is so severe as to simulate a true cerebral complication. 
General symptoms, as chills and fever, nausea, vomiting, sleep¬ 
lessness, dizziness, and vertigo, and general lassitude, have been 
observed and described by numerous authors. 

( c) Dilatation of walls. This results chiefly from cysts, muco¬ 
celes, and hydrops of the sinus, although Gerber 78 insists that it 
may also be dependent upon a pure empyema which has become 
encysted through occlusion of drainage. We do not propose to 
dispute this assertion with such eminent authorities (Killian 425 
and Gerber), yet from a purely physiological standpoint it would 
seem curious why a stronger wall (anterior) would yield before 
a weaker (posterior) to a uniform internal pressure from pent-up 
secretion. That the condition is a great rarity even these author¬ 
ities freely admit. 

Mucocele.— Several theories have been advanced for the for¬ 
mation of these mucoid collections: 1. From a previously-existing 
sinusitis which had never become infected or had lost its virulence, 
absolute occlusion of the ostium being presupposed. 426 2. From a 
cyst in the sinus mucosa which had retained its secretion. 427 * 428 
3. From an enlarged anterior ethmoid cell. 429 Traumatism is 
usually the immediate causative factor. These swellings progress 
slowly and, as a rule, without much pain, and are capable of 
reaching an enormous size, as is well illustrated by the classical 
case of Bartliausen (Fig. 141), in which the eyeball was dislo¬ 
cated almost below the nasal apertures. Their contents are quite 
characteristic, being composed of a mucoid substance of grayish, 
brownish, and even a chocolate color, being inodorous and usually 
sterile. They are, however, capable of infection, in which event 


425. Killian: Heymann’s Handbuch. Die Nase, S. 1124, 1900. 426. Logan Turner: 

Mucocele of the Nasal Accessory Sinuses. Edin. Med. Journ., Nov. and Dec., p. 396, 481, 
1907. 427. Onodi: Die Mucocele des Siebbeinlabyrinths. Arch. f. Lary., Bd. 17, S. 415, 
1905. 428. Sprenger: Ein Fall von Schleimhautcyste der Stimhohle. Arch. f. Lary., 

Bd. 19, S. 136, 1907. 429. Avellis: Die Entstehung der Nichttraumatichen Stirnhohlen- 
mucocede. Arch. f. Lary., Bd. 11, S. 64, 1901. 



Ophthalmic sinus 
V. ethmoid 


Cavernous sinus 


V. posterior facial 



V. frontal 


V. supra-orbital 


V. anterior facial -- 

Fig. 140.—Venous anastomoses of the nose and orbit, showing intimate relation. (After Quain.) 

















FRONTAL SINUS. 


259 


a true empyema is formed. The dilatation affects all of the walls 
of the sinus, and takes on the character of a continual reabsorption 
and thinning of the osseous structure rather than an actual dilata¬ 
tion. In old cases the walls may have lost entirely the bony consis¬ 
tency, which has been replaced by a tough membrane of connective 
tissue. The inferior wall is usually the first to show reabsorptive 
changes, which may in time cause that entire structure to disappear. 
The posterior or cerebral wall is affected next, or perhaps simul¬ 
taneously, but is not absorbed as quickly as the former; however, 
the extent of reabsorption may be so great as to expose three or four 
square inches of the dura over the frontal lobe. Dislocation of the 
eyeball occurs sooner or later from mucocele of the frontal sinus, and 
is always in the direction of downward and outward, in contradis¬ 
tinction to outward from the ethmoid and forwardfromthe sphenoid. 

The differential diagnosis between 
mucocele of the frontal sinus and 
orbital tumors occasionally offers 
some difficulties; however, needle 
puncture with aspiration will ac¬ 
quaint one with the character of the 
contents. Fluctuation is another 
sign wdiich malignant tumors of the 
orbit do not present. 

Hydrops 430 of the frontal sinus 
is, to all intents and purposes, a 
mucocele with clear watery contents. 

It is probably due to a serous out¬ 
pouring into the sinus with closure of 
the ostium—a condition which has 
continued for years. 

Pyocele is either an infected 
mucocele or a closed-in empyema in which the virulence of the in¬ 
fecting organism gradually became less effective until it reached a 
condition of innocuousness, the volume of the collection of purulent 
material remaining as before. All of these conditions are extremely 
chronic and require years before attaining any considerable growth. 

Oculo-orbital complications: These complications are usually 
antedated by some of the bone affections, particularly caries and 



Fig. 141.—Enormous mucocele of the 
frontal sinus dislocating the eye downward 
and outward. (After Barthausen). 


necrosis. 


430. Lichtwitz: Ueber die Erkrank. d. Sinus oder Nebenhohlen der Nase. Prager med. 
Woch., S. 311, 




260 


THE ACCESSORY SINUSES OF THE NOSE. 


They may be divided into the following: 

1. Affections of the orbit and cellular tissue. 

2. Affections of the adnexa. 

3. Affections of the bulb. 

4. Functional disturbances. 

1. The beginning stage of an orbital complication is an inflam¬ 
matory swelling of the orbital cellular tissue. This is always 
associated with a more or less persistent oedema of the upper eye¬ 
lid. The inflammation may be arrested at this point and grad¬ 
ually recede, only to appear again with greater severity on the 
next occasion of acute exacerbation of the frontal sinusitis. More 
often, however, it progresses in ratio to the virulence of the infec¬ 
tion, with the formation of an orbital abscess, or, in favorable 
cases, with a subperiosteal abscess and fistula. Diplopia is one 
of the most important symptoms in the earlier stages of this 
affection, as well as interference with the mobility of the bulb. 
Central scotomas are rare, being associated almost exclusively 
with affections of the posterior ethmoidal and sphenoidal 
sinuses. 

2. Affections of the adnexa. 431 The lids, tear-sac and duct, and 
external muscles are also subject to various affections through 
compression, infection, and toxic influences. 

3. Affections of the bulb. Dislocation of the bulb depends 
upon dilatation of the sinus walls, particularly the orbital from 
mucocele, pyocele, etc., and may take place without inflammatory 
appearances. Subperiosteal abscess causes forward and outward 
dislocation of the bulb, usually accompanied with inflammatory 
symptoms in the latter. The bulb may also become directly in¬ 
fected through the invasion of micro-organisms from the diseased 
sinuses. 

4. Functional disturbances. Disturbances of function some¬ 
times occur without the slightest sign of any inflammation outside 
of the sinus. Various causes have been attributed to this condi¬ 
tion, such as nervous reflex disturbances of circulation and reab¬ 
sorption of toxins from the affection cavities. 

Intracranial Complications.* 382 — The cerebral complications, 
like the orbital, are usually dependent upon the primary occur- 


* For a detailed and minute treatise on this subject, with extensive references, the 
reader is referred to the above-cited monograph of Gerber’s (also 382). 

431. Hoffman: Die Beziehung der entzund. Orbitalerkrankungen zu den Erkrank. 
der Nebenhohlen der Nase. Verh. deutsch Lary., S. 91, 1907. 



FRONTAL SINUS. 


261 


rence of some osseous lesion in the sinus walls. Occasionally, how¬ 
ever, the bone has been found to be macroscopically intact. Under 
these circumstances the perforating veins must have transmitted 
the infection. The various routes by which the infection can find 
its way into the cranial cavity have been already enumerated (see 
General Complications). Intracranial lesions dependent upon 
chronic frontal sinusitis may be classified as follows: 

1. Circumscribed plastic inflammation of the dura mater, cor¬ 
responding to the adjoining area of diseased bone. After the 
disease has penetrated the bone, that portion of the dura lying 
in apposition loses its shining aspect and appears hypergemic, 
thickened, and occasionally discolored. If the process continues, 
granulations and plastic exudate begin to form, which soon results 
in agglutination of the dura with the overlying bone. 

2. Circumscribed purulent inflammation of the dura mater 
(extradural abscess). The above process (circumscribed plastic) 
may become purulently affected, thus constituting either a cir¬ 
cumscribed ulceration or an extradural abscess. The formation 
of the latter occurs between the bone and the dura, and is 
dependent upon the formation of a plastic exudate at the line of 
demarcation between the healthy and diseased tissue, thus form¬ 
ing a barrier between the purulent collection and the general extra¬ 
dural space. 

3. Pachymeningitis interna, intra- and sub-dural abscess. 
When the inflammation reaches such intensity that the dura is 
unable to withstand its attack, the infection penetrates it, reaches 
the pia mater, and causes inflammation of this structure. If the 
purulent process becomes encysted, an infra- or sub-dural abscess 
results, otherwise the infection spreads over a considerable por¬ 
tion of the surface of the pia, resulting in diffuse purulent internal 
pachymeningitis. 

4. Brain abscess. 431 ® This grave complication of frontal sinus¬ 
itis is fortunately an exceedingly rare one as up to 1914, 
Boenninghaus 431b was able to collect but 87 cases. The prodromal 
symptoms are usually not well marked and are often conspicuous by 
their absence, however, certain manifestations occur which should 
be considered as significant, one of these being the headache. If this 

431a. Leegaard: Cerebral Abscesses of the Frontal Lobe Originating from the Frontal 
Sinus and Other Intracranial Complications Resulting from Inflammatory Processes of the 
Nasal Accessory Sinuses. Annals of Otol., Rhino, and Laryng.. March, 1919. 431b. 

Boenninghaus: Die Operationen bei den intra-kraniellen Komplikationen der entztindlichen 
der Nebenhohlen. In Katz, Preysing u. Blumenfeld. Handb. der spec. chir. etc. Bd. 3,1914. 



262 


THE ACCESSORY SINUSES OF THE NOSE. 


becomes very violent, more so than even could be reasonably ex¬ 
pected in the most severe type of uncomplicated frontal sinusitis, 
the chances are that some cerebral condition underlies the sinus 
affection. If the pain persists after the sinus has been opened and 
completely freed from its pathological contents, it is extremely 
probable that involvement of the deeper structures has already 
taken place. 

Symptoms pointing directly to the frontal lobe are rarely mani¬ 
fest except when the abscess extends well backward, then signs of 
brain pressure such as paresis and hemiphlegia appear. In all 
cases of frontal sinusitis in which improvement does not follow the 
external operation, brain abscess should be suspected. 

Treatment. This, of course, is surgical and consists of evacua¬ 
tion and drainage. The posterior wall- of the sinus must be made 
freely accessible even if removal of more of the anterior wall is 
necessary. A search is then made for any suspicious area such as a 
slight discoloration or fistulous opening. If one of these is found, the 
opening is enlarged at this point but in any event the dura must be 
laid bare, in area at least the size of a dime or larger. Puncture 
should then be made with a thick needle in order to avoid wounding 
the vessels of the pia unless the dura is badly discolored or a fistula 
is present, in which event the dura is incised with a sharp pointed 
knife before the puncture is attempted. The needle or knife used 
for puncturing can safely be inserted up to 2.5 centimetres without 
danger to the lateral ventricles. If pus is found, a crucial incision 
is made in the dura and the cavity drained but not in a continuous 
stream. A strip of iodoform gauze is inserted as far as the abscess 
cavity in order to keep the wound open and allow good drainage; 
the first dressing changed in twenty-four hours and thereafter, 
every two or three days depending upon the amount of secretion. 
Confinement to bed for four to six weeks is essential even though 
the patient appears quite well as sudden death has been reported 
from cerebral oedema in a patient getting up too soon. Macewen 4310 

Even when a cerebral abscess has been successfully located and 


431 c. Macewen: Progenic infective diseases of the brain and spinal cord. Glasgow, 1893. 



FRONTAL SINUS. 


263 


opened, there remains the danger of a secondary abscess forming 
posteriorly. This must constantly be borne in mind as the oc¬ 
currence of one of these may quickly turn an apparently favorable 
case into one that is hopeless. In operating, our one thought should 
centre itself on the installation of a free outlet for the purulent 
material with the least possible trauma to the surrounding tissues 
for despite every effort the prognosis is very grave, as up to the 
present, I have found reported only 33 cures in 88 cases of which 
had been subjected to operation, 431d , 4316 but this is misleading as the 
mortality of true brain abscess is over 70 per cent, following opera¬ 
tion and 100 per cent, where surgery is not applied. 

5. Thrombophlebitis results when the purulent material is 
carried directly into the longitudinal sinus and finds a place of 
lodgement along the walls. Pyaemia is usually the ultimate sequel 
of this condition. 

Although individual mention has been made of these condi¬ 
tions, yet they rarely occur singly, one being a forerunner of the 
other, depending upon the virulence of the infection and the 

43Id. Denker, Alfred,: Rhinogener Frontallappenabsces und extraduraler Abscess in 
derStirngegend, durch Operation geheilt. Archiv. f. Laryng., etc., Bd. 10, S. 411,1900. 431e. 
Butzengeier, O.: Zur Chirurgie des Stirnhimabscesses. Ein Fall von geheiltem Stirnhirnab- 
scess. Munchener med. Wochenschr. No. 45,1911. 43If. Cargill: Abscess in the Left Cerebral 
Frontal Lobe, Originating from Nasal Suppuration in the Left Frontal Sinus. Journ. of 
Laryng., p. 379, 1908. 43lg. Weiner, Alfred,: Abscess in the Frontal Lobe of the brain 
after chronic frontal sinusitis. N. Y. Med. Record, Oct. 22, 1910. 43 lh. Griinwald, L.: 

Stinkende Naseneiterung. Empyem beider Stirnhohlen, cariose Zerstorung der Hinterwand 
derselben, rechtseitige Pachymeningitis, Abscess des Frontallappens. Trepanation, Heilung. 
Munchener med. Wochenschr., No. 20, 1895. 43 li. Herzfeld: Rhinogener Stirnlappenab- 

scess, durch Operation geheilt. Berk kl. Wochenschr., No. 47, 1901. 431j. Rische, Hans: 

Ein erfolgreich operierter Himabscess nach Stirnhohlenerkrankung. Zeit. f. Ohrenhk., Bd. 
62 1911. 431k. Rawling: A case of Chronic Abscess of the frontal lobe. Trans. Med. 
Soc. of London, 1907. 4311. McCoy: Report of two cases of Brain Abscess in the Frontal 
Lobe. Ann. Otol., Rhin. and Laryng., p. 287, 1910. 431m. McCullagh: Abscess of the 

Frontal Lobe Simulating Frontal Sinusitis. Trans. Am. Laryng., Rhino, and Otol. Soc. 
1920. 431 n. Walker, N.: Abscess of the Frontal Lobe of the Brain Following Empyema of 
the Frontal Sinus. Liverpool Med. Chir. Journ., Jan., 1912, p. 189. 43lo. Lynch, R. C.: 
Abscess of Frontal Lobe of Brain. Amer. Laryng. Ass'n., p. 144,1917. 431 p. Lynch, R. C.: 

Brain Abscess, Recovery. Personal Communication. 431q. Harris: A case of Brain Ab¬ 
scess Dependent upon Empyema of the Frontal Sinus. Annals of Otol., Rhino, and Laryng. 
Sept., 1919. 43lr. Dean: Brain Abscess, Recovery. (Evacuation Through Nose) Personal 

Communication. 43Is. Hardie: Brain Abscess, Recovery. Personal Communication. 
43It. Haugseth: Fall von geheiltem rhinogenem Gehirnabszess. Ref. Centralbl. fur Laryn- 
gologie, S. 181, June, 1920. 43 lu. Mackenzie, Dan.: Brain Abscess following frontal sinus¬ 
itis. Operation. Recovery. Laryngological Section, Royal Society of Medicine, Nov. 1914. 
43lv. Pierce: Discussion. Trans. Amer. Laryngological Assn., p. 75, 1922. 




264 


THE ACCESSORY SINUSES OF THE NOSE. 


powers of endurance of the patient, for death claims practically all 
of the sufferers—certainly, if the disease has acquired any consider¬ 
able headway. As rhinologists our one and only chance lies in the 
immediate recognition of these cerebral complications at their very 
onset and the institution of appropriate radical treatment. It must 
always be borne in mind that a brain abscess, once formed, offers 
a far better prognosis for ultimate recovery than during its early 
or formative period, for the fact of a circumscribed collection of 
pus is proof that the patient is responding to an effort of nature to 
limit the pathologic process and thus bring about a cure. The 
surgeon can lend timely aid in this direction by establishing early 
drainage with the least amount of trauma and subsequent infection 
to the surrounding healthy brain tissue. 43lb That this may be suc¬ 
cessfully accomplished is well illustrated in the case of Stone, 431 a 
in which a cure was brought about in a case of intracranial involve¬ 
ment from frontal sinusitis by exploration and drainage even 
though the patient had been seized with convulsions, also, two of 
brain abscess from chronic suppuration of the frontal sinus that 
were cured by opening and drainage. 43 lc * 431d That this is most dif¬ 
ficult, often impossible, will be shown under the following heading. 

Diagnosis .—The symptoms of beginning meningeal complica¬ 
tions and those of a severe attack of uncomplicated frontal sinusitis 
may be, to all intents and purposes, identical. The course of a 
severe frontal sinusitis may continue for days unchanged, when 
suddenly threatening symptoms supervene and on operation a 
meningeal complication of considerable extent is discovered. This 
is peculiarly applicable to those cases of meningitis following 
frontal sinus disease. Usually, however, certain symptoms mani¬ 
fest themselves at the onset of the complication. 

In the first place, there is a decided but indefinite change in the 
general condition of the patient. This may take the form of an 
intensity in the headache, which also changes in location. If the 
pain was previously limited to the frontal region, the entire 
cranium becomes involved. The sudden appearance of an oedema 
of the upper lid on the affected side is of the greatest diagnostic 
importance, denoting the beginning of cerebral invasion, and de- 


43!a. Stone: Long Island Med. Journ., Nov., 1917. 431b. Berens: Brain ahscess 

From Chronic Suppuration of the Frontal Sinus. Ann. of Otol. Rhin. and Laryng., p. 341, 
1917. 431c. Mollison, W. M.: Case of Frontal Sinus Suppuration: Suppurative Menin¬ 
gitis for Fourteen Davs: Operation and Recovery. Proc. Royal Soc. Med., Section on 
Laryng., June, 1918. 43Id. Leegaard: Cerebral Abscesses of the Frontal Lobe Originating 
from the Frontal Sinus and Other Intracranial Complications Resulting from Inflammatory 
Processes of the Nasal Accessory Sinuses. Annals of Otol. Rhino, and Laryng., March, 1919. 



FRONTAL SINUS. 


265 


mands instant surgical intervention. Marked changes in the eye- 
grounds also demand careful attention. Sudden heat flashes 
frequently appear. The patient at first seems disquieted, sleepless 
and restless, although no definite cause can be attributed to these 
symptoms. As the complication develops the physiological changes 
give way to actual meningeal manifestations, such as vertigo and 
dizziness, nausea and vomiting, and photophobia. Neither the pulse 
nor the temperature is characteristic, as sometimes there is 
fever, sometimes subnormal temperature. The pulse may be fast 
or slow, but the former is usually the case. When the compli¬ 
cation has actually taken place, symptoms of stupor, delirium, 
etc., with all the appearances of cerebral irritation or com¬ 
pression, appear. 

Thrombophlebitis following frontal sinus empyema is such a 
rarity that it will be described under the sinus from which it most 
commonly originates (sphenoid). 

Treatment. 

When an ordinary uncomplicated case of chronic frontal sinu¬ 
sitis presents itself for treatment we are confronted by one of the 
two following possibilities: either that ( a ) the institution of free 
drainage and ventilation will bring about a cure, or, at least, an 
amelioration of all symptoms, so that only a thin serous discharge 
persists; or that ( b ) the sinus mucosa has undergone such changes 
as to preclude the possibility of a cure except through radical 
operative measures. 

A certain amount of information regarding these probabilities 
may be obtained by rhinoscopy. If the middle passage seems oc¬ 
cluded by any of the conditions previously mentioned (see page 
246), we would naturally infer that these stand in direct relation 
to the subjective symptoms. If, on the contrary, the drainage 
passages seem patulous, the prospect of a successful issue follow¬ 
ing continued irrigation is considerably diminished. In doubtful 
cases the radiograph may throw considerable light upon the con¬ 
dition, especially upon the presence of finger-like projections with 
foci of disease at their extremities, as well as partial septa and 
fossae-hiding areas of hypertrophied and granular patches of 
mucosa. 

Let us then consider that we are called upon to treat an ordinary 
case which has never before been under special treatment. What 
procedure shall we primarily adopt? Our first thought will be to 


266 


THE ACCESSORY SINUSES OF THE NOSE. 


ascertain whether the continually-forming secretion in the frontal 
sinus finds an unhindered passage into the nose. This is the first 
principle in the treatment of any sinus affection and applies par¬ 
ticularly to the frontal, as the ostium lies in the most favorable posi¬ 
tion for constant drainage. Presuming that no polypoid formations 
are present, we note that the middle turbinate is either swollen at 
its anterior extremity so that it encroaches on the middle nasal 
passage, or it lies sufficiently close to the lateral nasal wall to 
effectually prevent the passage of a sound into the sinus. 

As it is absolutely essential that this structure should be removed 
from its position, two courses are open: 1. Infraction of the middle 
turbinate. 2. Resection of the anterior third of the middle turbi¬ 
nate. Infraction of this structure is contra-indicated when the 
nasal septum is deviated toward the affected side or the turbinate 
is so enlarged as to prevent its dislocation. Let us suppose, how¬ 
ever, that all conditions were favorable for this procedure and it 
was successfully accomplished. (For technic see p. 233.) As 
no bleeding to obstruct our vision has occurred, we proceed imme¬ 
diately to the introduction of a suitable sound, which is followed 
by a catheter and irrigation. 

This procedure often temporarily relieves the patient, but a permanent cure 
rarely results, for the following reasons: The infracted turbinate shows a marked 
tendency to resume its original position and, the permanent ventilation being thus 
interfered with at the next attack of acute rhinitis, the sinus will start anew to sup¬ 
purate with return of the original symptoms. 

Suppose, despite the room acquired by breaking the turbinate 
against the septum, it does not suffice for proper irrigation, what 
is the next step to pursue? We can now procure more room only 
by sacrificing a certain amount of tissue, and that best adapted 
for our purpose is the anterior third of the middle turbinate. 

RESECTION OF THE ANTERIOR PORTION OF THE MIDDLE TURBINATE. 

Technique: 1. Cleanse the nares with douches of warm saline 
solution. 

2. Cocainize middle turbinate with 20 per cent, solution of 
cocaine with few drops of adrenalin chloride, care being taken to 
introduce the cotton pledgets as high up as possible in the middle 
nasal passage between the bulla and turbinate, as well as between 
the turbinate and septum. Repeat this several times and wait at 
least fifteen minutes. 


FRONTAL SINUS. 


267 


3. Pry out the turbinate from the lateral nasal wall if necessary 
and introduce scissors on each side of the turbinate at its anterior 
attachment, pushing them well up until firm resistance is encoun¬ 
tered. (Fig. 134.) 

The cribriform plate cannot be injured by this procedure, as the outer blade 
will meet with firm resistance before the inner is near this structure. As the shank 
of the snare must occupy this incision it is important that it be made correctly and 
as high as possible. 

4. The turbinate is severed by one firm cut of the scissors and 
the shank of the snare worked gently upward until it reaches the 
highest extremity of the cut, the loop encircling the turbinate about 
at its middle. (Fig. 136.) 

It sometimes requires considerable patience to successfully carry out this 
manoeuvre, as the loop often catches orr various obstacles before finally reaching 
its position. No end of trouble, however, should be spared, as the successful applica¬ 
tion of this step has much to do with the ultimate result of the operation. 

5. The snare is slowly but firmly contracted until the end of 
the wire cuts through the turbinate and disappears into the shank 
of the instrument. 

In preparing the snare it should always be tested to ascertain that the end of 
the loop will completely sink into the shaft, otherwise it may be necessary to 
readjust it in the midst of the operation. 

Little or no bleeding will occur if the parts have been suffi¬ 
ciently adrenalized. 

6. Remove the severed piece with a pair of serrated alligator 
forceps; otherwise it may be pushed farther into the nasal cavity 
and ultimately lost. 

7. Remove any irregular portions of loose bone or membrane 
with the cutting forceps. An attempt should now be made to 
sound the sinus, which will succeed in 95 per cent, of all cases. 
After the successful introduction of the instrument the patient 
should be allowed to remain away for several days until healing 
sets in. Lavage should now be regularly instituted and con¬ 
tinued for an indefinite time, depending upon the condition of 
the patient. 

The question as to how long lavage should be continued depends upon a great 
number of eventualities, including the personal views of the rhinologist as to the 
indications for radical procedures. This perhaps explains why certain operators 
report many more operations than their colleagues of equal experience in number 
of patients treated. If the subjective symptoms are greatly ameliorated and the 


268 


THE ACCESSORY SINUSES OF THE NOSE. 


patient is fairly comfortable, the indications for further operative treatment lies 
entirely with him, as no complications are to be feared as long as free drainage con¬ 
tinues. That this ‘conservative course is the proper policy to pursue is shown by 
the scores of patients who have recovered after months of treatment. Hajek tersely 
brings out this point by reporting a case which refused operation although it was ap¬ 
parently indicated. He chanced to meet the patient about a year afterwards, and on 
noting his perfect health, inquired who had performed the operation. He was sur¬ 
prised to receive the answer that it had completely healed of its own accord. 

Should the disease apparently succumb with the exception of a slight discharge, 
it is well to inject a medicated liquid after the lavage. A 2-5 per cent, solution 
of nitrate of silver frequently reaches the chronically diseased areas and brings 
about entire cessation of the secretion. The head of the patient should be inclined 
strongly forward immediately after the injection, so as to allow the fluid to remain 
in contact with the diseased mucosa as long as possible. It must, however, always 
be borne in mind that this sinus once diseased constitutes a weak spot in the human 
economy which is always liable to become reinfected. 



Suppose, in spite of frequent irrigations, the condition of the 
patient showed very little improvement, should we advise an 
external operation? When we consider the probabilities why 
improvement has not taken place in that sufficient drainage and 
aeration have not been established and that intranasal measures are 
still open to us, this question should be answered in the negative. 
It is yet possible to obtain considerably more room by resecting the 
uncinate process and curetting the anterior ethmoid cells lying 
in apposition to the semilunar hiatus. The fact that the ethmoid 
cells are practically always involved strengthens considerably the 
indications for this form of operative procedure. 

RESECTION OF THE UNCINATE PROCESS. 

Technique: 1. Cocainize the parts as before. 

2. Introduce a modified hook (Fig. 142) over the uncinate 
process and by a quick jerk tear it loose from its attachment. 
(Fig. 143.) 

3. Curette the hiatus from behind forward and above down¬ 
ward until the opening is considerably widened. 432 (The eth¬ 
moidal bulla must be removed if it interferes in any way with 
this procedure.) 

432. Worthington: The Intranasal Frontal Sinus Operation: the Accessibility of 
the Sinus and the Prognosis of the Operation. Laryngoscope, p. 940, 1909. 







Fig. 144. —Using Lange’s forceps to enlarge the 
naso frontal passages. 


Fig. 143.—Removing the uncinate process with the 

nasal shave. 




* * 
















* 




































































































































FRONTAL SINUS. 


269 


Great care must be exercised not to forcibly push the end of the curette too 
far upward, lest the cribriform plate be injured. The direction of the curette must 
never be outward for fear of traumatism to the orbital plate, particularly through 
the lachrymal fossa. 

4. Remove all hanging debris and projecting bony spicules 
with a Lange forceps (Fig. 144), sounding the opening from time 
to time until it appears quite patulous and as large as possible 
under the existing circumstances. (Fig. 145.) 

Bleeding may prove a source of serious inconvenience to the 
operator at this point, and if it cannot be controlled by the appli¬ 
cation of gauze soaked in adrenalin 1-1000, the completion of the 
operation had best be postponed for two or three days. 

After this procedure it is often possible to introduce a fairly 
large hard-rubber Eustachian catheter and irrigate the sinus with 
a stream of considerable size. The pressure at the beginning, 
however, must be moderate, otherwise disagreeable results, such 
as syncope or severe pain, might ensue. This treatment, followed 
by regular lavage and the occasional removal of exuberant granula¬ 
tions, offers the best possibilities for cure by intranasal treatment. 

INGALS >S INTRANASAL OPERATION. 433-435a 

The rationale of this operation is to enlarge the fronto-eth- 
moidal passages with an electric burr to such an extent that good 
drainage is insured. A self-retaining gold tube is then inserted to 
prevent narrowing from granulation tissue formation. 

Technique: 1. ‘Cannula introduced into sinus and cavity 
washed out with a warm saturated solution of boric acid. 

2. Anaesthetize with 20 per cent, cocaine hydrochloride in a 
solution 1-1000 suprarenalin, applying it to the frontal sinus 
through the long silver nozzle of a syringe; about one-third minim 
every ninety seconds, five or six times. A weaker solution is used 
in the nares before the manipulations are begun. 

3. Introduce steel pilot and, with the patient in a sitting posi¬ 
tion, administer ethyl chloride for a minute or two. 

4. Remove handle from pilot, slipping on the hollow burr, and 
attach to dental engine. 


433. Ingals: New Operation and Instruments for Draining the Frontal Sinus. La¬ 
ryngoscope, p. 644, 1905. 434. Ingals: Intranasal Drainage of the Frontal Sinus. Laryn¬ 
goscope, p. 113, 1910. 435. Ingals: Intranasal Drainage of the Frontal Sinus. Journ. 

Am. Med. Assoc., p. 1502, May 9, 1908. 435a. Ingals: Intranasal Drainage of the Frontal 
Sinus. Ann. of Otol. Rhin. and Laryng., p. 656, 1917. 



270 


THE ACCESSORY SINUSES OF THE NOSE. 


5. Push burr up into the nares until it engages in the lower 
end of the nasofrontal canal. (Fig. 146.) 

6. The electric current is now applied and the burr gently 
pressed upwards, so that in two or three seconds it cuts its way 
into the frontal sinus. 

7. Introduce packer into the enlarged canal and pack sinus 
with gauze saturated in 20 per cent, solution chloride of zinc, 
allowing it to remain five minutes. 

8. A gold tube (Fig. 147), the upper end of which has been 
sprung together and covered with a gelatine capsule, is slipped 



Fig. 145. —Operation completed. Cotton 
carrier armed with a large wad of cotton easily- 
penetrating the opening into the frontal sinus. 



Fig. 146.—Ingals operation. The flexible burr boring into 
the frontal sinus. 


on an applicator and passed up the canal as far as possible into 
the frontal sinus. 

Leaving the tube in situ concludes the operation. 

The gelatine capsule melts in the course of a few minutes, 
allowing the end to expand. After-treatment consists of regular 
lavage with a strong boric acid solution: the patient may be taught 
to do this himself. The gold tube should remain in place about 
four months, but may remain even longer if deemed necessary. 
Ingals has treated about fifty cases by this method and reports 
95 per cent, of cures. 

I have had no experience with this method, therefore, any endorsements or 
objections here must naturally be of a theoretical nature. The following points, 
however, may be mentioned: 


FRONTAL SINUS. 


271 


1. Any rapidly revolving instrument, particularly when hidden in such 
proximity to the lamina cribrosa, is dangerous, even in skilled hands. 

2. When a suppurating orbital cell is present, the body of the tube could 
easily occlude the ostium with damming back of the secretion. 

3. Where great pathological changes have taken place in the sinus mucosa 
the operation will probably be unavailing. 

Even considering these objections, it must be admitted that in the hands of 
Ingals, this operation has proved to be of decided worth. 

HALLe’s INTRANASAL OPERATION. 436 ’ 437 

This author removes the anterior-superior spine which forms 
the anterior portion of the floor of the frontal sinus, thereby 
creating a large and permanent opening into the nose. 

Technique: After having a Roentgen photograph taken for 
the purpose of orientation, 

1. Remove anterior end of middle turbinate. 



Fig. 147.—Ingals gold tube for intranasal insertion into the frontal sinus. The lower cut shows the tube 
with the gelatin capsule over the end. 


2. Cocainize with 10-20 per cent, cocaine and adrenalin solu¬ 
tion, and inject into sinus 0.5 per cent, novocaine and adrenalin 
solution. 

3. Introduce sound as high as possible into the frontal sinus, 
over which is slid a soft, flexible metal protector which ad¬ 
justs itself to the tabula interna posteriorly and to the orbit 
laterally. 

4. Remove the sound and introduce drill alongside the pro¬ 
tector. Press instrument firmly to the front and apply current, 
taking care to keep always close to the protector. (Fig. 148.) 
Any lateral deviation of the instrument must not be permitted. 

During the boring it is wise to make a number of interruptions in order to 
inspect the parts and to allow the burr to cool. It is of the utmost importance to 
keep the operation under the control of the vision. 


436. Halle: External or Internal Operation for Suppuration of the Nasal Accessory 
Sinuses. Laryngoscope, p. 115, 376, 1907. 437. Halle: Arch. f. Laryng., Bd. 24, S. 

249, 1911. 




m 


THE ACCESSORY SINUSES OF THE NOSE. 


5. After the drill lias entered the sinus, it is removed and a 
pear-shaped one substituted, which is rounded off and polished 
so that it cannot cut in an upward direction. With this instrument 
the sides of the wound are reamed off until a large, smooth open¬ 
ing is made into the sinus. (Fig. 148a.) 

6. Remove polyps and degenerated mucosa with a double 
curette. 

After-treatment: Cavity is packed with iodoform gauze, which 
is allowed to remain in place three to four days. A silver tube 
similar to Ingals’s is now introduced and may remain indefinitely 
in situ, (several months to one year). The patient is not permitted 



to practise irrigation on himself, but reports once or twice weekly 
for this purpose. Nitrate of silver is used to control granula¬ 
tions. 

Halle has treated 28 cases by this method, with 18 cures and one 
death from meningitis. One later required an external radical opera¬ 
tion, and even then was not benefited. The entire procedure requires 
5 to 15 minutes, and is followed by little or no postoperative shock. 

Contra-indications: 1. In those cases in which it is impossible 

to sound the frontal sinus. 

2. When the sinus is inordinately large and contains numerous 
ramifications. 

3. When complications have set in. 





FRONTAL SINUS. 


273 


halle’s improved method. 4374 

1. Cleanse the external nose and neighboring parts with alcohol 
and iodized benzine. The introitns is sterilized with tincture of 
iodine applied on a cotton pledget. The head is bound with sterile 
gauze. 

2. Anaesthetization. The mucosa of the lateral wall is thor¬ 
oughly painted with a 10 per cent, solution of cocaine. This is 
confined to that portion lying anterior to a line drawn from the 
anterior thirds of the middle and inferior turbinates, particularly 
beneath the middle turbinate in the region of the bulla. One-half 
of 1 per cent, solution of novocaine is injected in the mucosa in the 
region of the agger nasi and externally under the periosteum over 
the root of the nose. 

3. Formation of the mucoperiosteal flap on the lateral nasal wall. 
A long, slender knife is carried as high as possible along the roof 
of the nose and a curved incision made through mucous membrane 
and periosteum, beginning in front of the anterior attachment of 
the middle turbinate and ending below the anterior end of the middle 
turbinate in the middle nasal passage. (Fig. 149, A.) A second in¬ 
cision is made along the nasal roof anteriorly to about the piriform 
aperture, then is carried downwards and ends at the anterior at¬ 
tachment of the inferior turbinate (Fig. 149, A). The thus-formed 
mucoperiosteal flap is now carefully elevated from the bone by 
means of a thin elevator and turned downwards and backwards, 
being held in place by a thin strip of gauze (Fig. 149, B). It is 
astonishing how much larger the operating field is made by this 
resection. 

4. The anterior attachment of the middle turbinate is now freed 
from the ascending branch of the superior maxillary by means of 
scissors or a chisel and the whole turbinate pushed over towards 
the nasal septum. If the agger nasi is so situated as to interfere 
with the view, it can easily be reduced with a few blows on the chisel 
or smoothed down with the electric burr. All danger is avoided by 
careful work, as every manipulation is under direct control of the 
vision. After removing the debris from the broken-down anterior 
ethmoidal cells the opening of the frontal sinus comes clearly into 
view. 

5. Removing the inferior wall of sinus. After sounding for pur¬ 
poses of orientation, the smallest size pear-shaped drill is introduced 
into the frontal ostium directly under control of the eye, and the 

437a. Halle: Die Intranasalen Operationen bei Eitrigen Erkrankungen der Neben- 
hohlen der Nase. Archiv. f. Laryng., 1, Bd. 29, H. 1, S. 73, 1914. 



274 


THE ACCESSORY SINUSES OF THE NOSE. 


anterior superior nasal spine (floor of the frontal sinus) removed 
from behind forward and above downward (Fig. 149, D). The 
burrs should he changed to larger sizes as necessary. The instru¬ 
ment should never be used on the medial side, for fear of opening 
the adjoining frontal sinus. The floor of the sinus is removed to 
whatever extent desired, the size of the opening varying between 
1 x % to 2 x 3 cm. (Fig. 149, E). 

6. Curetting the sinus mucosa. By the introduction of sharp, 
flexible curettes the interior of the sinus can he thoroughly gone 
over (Fig. 149, D). Care must be taken not to use great force over 
the anterior and medial wall. The curettes, however, should be 
made of flexible copper, so that they will bend on the application of 
too great force. 

7. The mucoperiosteal flap is now replaced, extending as far as 
possible into the sinus, and held in place by a strip of vioform gauze. 
The middle turbinate is replaced on its original position, and after 
a few days, even after this extensive procedure, the interior of the 
nose shows only, on careful inspection, any traces of the operation 
(Fig. 149, F). 

Advantages of this method: 

1. The middle turbinate is preserved. The-function of the nasal 
mucosa is not impaired. 

2. The ethmoid labyrinth can be completely exenterated, using 
the middle turbinate as a guide and protector against injury to the 
lamina cribrosa. 

3. The frontal sinus can be opened under continual control of 
the eye to the greatest possible anatomical extent. 

4. The mucoperiosteal flap, when properly replaced, prevents 
the formation of granulations, synechia, and scar tissue, thus 
guaranteeing a permanent opening into the sinus cavity. 

Halle has operated upon 48 cases after this method (9/1/14); 
34 have been permanently cured. The remaining 14 have shown 
great improvement, the secretion having reached a minimum. 

GOOD’s INTRANASAL OPERATION. 438 

The principle of this procedure depends upon the removal of the 
sinus floor with a rasp after a portion of the frontal process of 

438. Good: An Intranasal Method for Opening the Frontal Sinus, Establishing the 
Largest Possible Drainage. Laryngoscope, p. 266, 1908. 






Fig. 149 .—Halle’s method. A. Preliminary incision, 
shaped breve. D. Floor of sinus removed. Fi. 


B. Flap turned back. C. 
Curetting interior of sinus. 


Opening sinus with pear- 
F. Flap replaced. 





























Fig. 1506. —Incision for exploratory opening of frontal sinus. 




Fig. 150c. —Incision through periosteum and opening in frontal sinus. 


















FRONTAL SINUS. 275 

the superior maxilla has been chiselled away to gain room for its 
entrance. 

Technique: Under local anaesthesia: 

1. Removal of middle turbinate. 

2. Removal of ethmoidal cells and unciform process. 

The ethmoidal cells are removed with Ballenger’s knife and the uncinate process 
with a chisel and biting forceps. 

3. A small portion of the frontal process of the superior max¬ 
illa is now chiselled away and the anterior medial wall of the 

ethmoid labyrinth separated 
from its attachment to the 
frontal spine. 

4. The rasp is introduced 
and the lateral aspect of the 
frontal spine gradually filed 
away, thus enlarging the space 
between the spine and the orbi¬ 
tal wall of the sinus. (Fig. 150.) 

The rasp is introduced into the 
sinus externally, to the frontal spine, 
and by rasping forward and towards 
the septum the space between the spine 
and the orbital wall is enlarged. The 
rasp is so constructed that neither the 
internal table nor the orbital wall of 
the sinus can be injured. 

5. The interior of the sinus 
is now curetted, if pathological changes have taken place in the 
mucosa, after which the cavity is packed with gauze. 

After-treatment: The gauze is removed on the following day. 
In very chronic cases with profuse discharge a gold-plated tube 
made of coarse wire-cloth is inserted to keep the ostium from closing 
with granulations. Good states that the operation can be per¬ 
formed under local anaesthesia, but during the rasping it is better to 
have complete narcosis. 

Thomson's modification of good's method. 439 

This author, instead of chiselling away the bone in front of the 
probe, introduces a pointed rasp with a groove in the back so that 
it fits over the probe, and, passing it up as far as possible under 

439. Thomson: A Safe Intranasal Method of Opening the Frontal Sinus. Laryngo¬ 
scope, p. 810, 1910. 




276 THE ACCESSORY SINUSES OF THE NOSE. 

reasonable pressure, withdraws it, thus cutting away the bone 
downward and forward. By repeating this movement, inserting 
the rasp higher into the duct each time, it is possible to work 
through into the frontal within a very few minutes and with practi¬ 
cally no pain to the patient. As soon as the frontal is opened, dif¬ 
ferent sized rasps, curettes, or forceps can be used to cut away all of 
the diseased bone in the anterior ethmoid cells without destroying 
the mucous membrane on the posterior wall of the nasofrontal duct. 
The introduction of a canula, with irrigation, is as a; rule not to be 
recommended immediately following the rasp. This particularly 
applies to a stiff, inflexible canula, as I have seen two deaths from 
meningitis, one in ten days, the other in twenty-nine days, follow its 
use. In both cases, the patients complained of severe pain the 



moment the injection was attempted, as though the fluid had 
touched an exquisitely sensitive part. The sinus condition instead 
of improving appeared to go from bad to worse until meningitis 
and death finally ensued. I have never seen this in any case where 
the rasp was used alone. No drainage tube is necessary, as the 
mucosa left in its natural position without impairment to its nutri¬ 
tion will grow over the bone bared by the rasp. Healing thus 
occurs more rapidly. 

Sullivan 439a has improved on this method by using graduated 
rasps (Fig. 150a). The smallest size’ which is but slightly larger 
than the ordinary nasal sound, is introduced first and the naso¬ 
frontal passages enlarged by rasping away the thin lamella of the 
infundibular cells. If the point of the rasp does not enter the sinus 
at the first attempt, after one or two downward strokes, intro¬ 
ducing the point as high as possible each time, sufficient room is 
gained to enable it to slip easily into the cavity. After several more 

439a. Sullivan: New Instruments. Laryngoscope, p. 132, 1913. 











FRONTAL SINUS. 


277 


strokes the next larger size is used, and so on until the largest rasp 
easily enters the sinus and by which the operation is completed. The 
method is quickly performed, reasonably safe, and is to be recom¬ 
mended when simple enlargement of the drainage passage is desired. 

COMPARATIVE VALUE OF THE INTRANASAL OPERATION. 

Experience teaches us that the vast majority of cases of frontal 
sinusitis, both acute and chronic, respond favorably to intranasal 
measures. The entire subject is dependent upon the condition of 
sufficient drainage to allow free egress of the inflammatory secre¬ 
tion, thus permitting resolution of the infected mucosa. So long as 
this drainage is free it is of little moment whether the drainage 
passages are excessively large or only of sufficient size to permit 
the escape of all the secretion. Either condition will usually result 
in a cure. 

Experience also has taught us that the high removal of the an¬ 
terior half of the middle turbinate with curettage of the ethmoid 
cells in the immediate neighborhood of the nasofrontal passages 
will in most cases suffice to accomplish the desired result. 

The various intranasaloperations described require a skill and 
proficiency that are only obtainable after the sacrifice of a consider¬ 
able amount of time and trouble by numerous experimental opera¬ 
tions on the cadaver. To our minds, they are only indicated after 
the ordinary intranasal method has been tried and found wanting; 
even then there is no guarantee that they will prove efficacious. 

The average of cures by removal of middle turbinate and 
curettage is about 95 per cent. The other 5 per cent, go to some 
form of external radical operation. Certain of this latter 5 per cent, 
are undoubtedly amendable to the more radical intranasal pro¬ 
cedures, but even the authors of these measures state that not all 
cases are amenable to this treatment. The whole matter then re¬ 
solves itself into the proposition of drainage. In the 5 per cent, of 
cases which do not respond to betterment of drainage, pathological 
changes have occurred within the sinus which demand their re¬ 
moval before resolution will set in. If the sinus is large, with ramifi¬ 
cations and partial septa, not to mention the presence of infected 
orbital ethmoidal cells, any intranasal effort will prove unavailing. 

It would, therefore, seem that these methods are only indicated 
in those cases in which the ordinary, conservative intranasal 
method had been tried without result, yet were not severe enough 
to demand an external operation. 

440. Hajek mit Diskussion: Ueber Indikat.ionen zur Operative Behandhmg bei der 
chronischen Stirnhohlenentzundungen. Verh. d. Deutsch. Laryng. Gesell., S. 123, 1907. 



278 


THE ACCESSORY SINUSES OF THE NOSE. 


INDICATIONS FOR EXTERNAL RADICAL OPERATION. 440 ’ 441 

Let us suppose we had operated by the intranasal route and 
although a certain amount of relief was experienced by the patient, 
nevertheless the disease persisted, how long should we wait before 
advising an external operation! This question cannot be answered 
offhand, as every case is almost a law unto itself. Before contem¬ 
plating any external procedure we should ascertain so far as pos¬ 
sible the internal condition of the sinus. The size and shape can be 
learned by means of the X-ray. Bacteriological examinations must 
be made to determine the nature of the infection, for should pure 
cultures be obtained the vaccine treatment by autogenous or stock 
vaccines is at once indicated. 

The temperament, social position, age, and sex of the individual 
must also, naturally, be considered; as, for example, a woman with 
chronic frontal sinusitis might easily develop into a confirmed 
neurotic individual unless measures were taken for the prompt 
suppression of the symptoms. On the other hand, a patient may 
experience so much relief from intranasal opening that he would 
under no circumstances consider an external cutting operation in 
order to be freed from the discharge and occasional pain. In gen¬ 
eral, the best plan to follow is to wait as long as no urgent symp¬ 
toms prevail and the patient does not experience too much dis¬ 
comfort from the discharge and occasional headache, as such cases 
generally slowly improve. The indications for an external opera¬ 
tion then may be divided into : relative and absolute. 

1. Relative indications:( a) when the X-ray shows a large sinus 
with many ramifications; (b) when, despite frequent irrigations, 
the pus continues foetid; (c) when headache continues with no 
apparent change in the secretion. 

2. Absolute indications:( a) when the subjective symptoms are 
severe enough to interfere with the business pursuits of the 
patient; ( b ) when severe exacerbations occur; (c) in abscess and 
fistula formations; ( d ) in threatened cerebral and orbital compli¬ 
cations; (e) actual appearance of complications. 

EVOLUTION OF THE EXTERNAL OPERATION ON FRONTAL SINUS. 

Before the days of rhinoscopy the operation universally prac¬ 
tised was simple trephining, followed by external drainage. 

441. Coakley, Kyle, Loeb: Symposium on Accessory Sinuses. Trans. A. M. A., Sec. 
on Laryngology, p. 193, i909. 



FRONTAL SINUS. 


279 


EXPLORATORY OR CONSERVATIVE OPENING. 

Method: 

1. An incision is made through the eyebrow, beginning below its 
inner margin and extending outward about one inch (Fig. 150b). 
This is carried down through the periosteum. 

2. The periosteum is elevated above and below until a sufficient 
area of bone is exposed. 

3. A small opening is made in the bony wall immediately above 
the maxilla-frontal suture (Fig. 150c). 

4. The sinus is flushed out with sterile salt solution and examined 
with a sound. 

Indications: 

1. Acute or acute exacerbations of a chronic purulent sinusitis 
in which the intranasal methods have failed to relieve. 

2. As an exploratory operation in doubtful cases. 

3. As a preliminary step in all radical operations. 

A refinement in this technique occurred when drainage into the 
nose was also made by enlarging the nasofrontal passages 442 - 
through the small opening in the anterior wall. Resection of the 
entire anterior wall, with an attempt to bring about an obliteration 
of the sinus, seems to have been in vogue around the year 1882. 443 
The sinus was thoroughly curetted and allowed to heal by granu¬ 
lation, keeping the external wound open—a long and tedious proc¬ 
ess. Ogston 444 appears to have been the first operator to suggest 
and practise removing the anterior ethmoid cells bordering on the 
uncinate process through the break in the anterior frontal sinus 
wall. Luc 445 further modified this procedure by introducing a 
rubber drainage tube, bringing it out through the nose and closing 
the original wound. 


This procedure proved highly successful, as it permitted immediate closure of 
the external wound, which usually healed by first intention. It was, however, noted 
that a marked predisposition to secondary infection occurred. This manifested 
itself usually about the twentieth day by an oedematous swelling over the operated 
area, which finally broke down and suppurated, often necessitating a secondary 
operation. This occurred usually in those cases in which the sinus was large or 
the anterior ethmoid cells extensively affected; when a small sinus was present and 
the ethmoid cells but slightly diseased, the results were ideal not only from a cura¬ 
tive but a cosmetic standpoint as well. 


442. Steiner: Arch. f. klin. Chirurg., Bd. 13, S. 144, 1872. 443. Kocher: Empyem 
und Hydrops der Stirnhohle. Bern, 1882. 444. Ogston: Trephining the Frontal Sinus, 
etc. Med. Chronicle, vol. 1, p.235, 1884. 445. Luc: Lecons sur F suppuration, etc., p. 
291. Paris, 1900. 



280 


THE ACCESSORY SINUSES OF THE NOSE. 


Kuhnt 446 went a step farther in removing the entire anterior 
wall of sinus, curetted thoroughly the mucous membrane, and 
applied external drainage with the object of obliterating the 
cavity by granulation. 

Technique .—A horizontal incision is made from inner end of eyebrow to outer 
third of supra-orbital ridge, a perpendicular incision made from internal end of 
brow reaching above, thus forming an L-shaped wound. The periosteum with over- 
lying soft parts is elevated and the entire anterior sinus wall removed. The cavity 
is freed from all ridges and partial septa and the mucous membrane thoroughly 
removed with the curette. A rubber drainage tube is sewed into the sinus at the 
junction of the two incisions. After-treatment consists of daily irrigation of the 
cavity with bichloride solution, and, if granulations are not free, with nitrate of 
silver or chloride of zinc solution. 

While Kuhnt brought out two important facts necessary in 
the healing of a frontal sinusitis, namely, that the partial removal 
of sinus wall did not reach all diseased hollows, and that very 
free drainage was indispensable, nevertheless his method has 
several disadvantages. Chief among these are (a) the length of 
time the fistula remains open; (b) the postoperative deformity; 
( c ) the complete failure when deep orbital processes are present, 
and ( d) the diseased ethmoid cells are left undisturbed. Coak- 
ley 447 modified this method by packing the frontal sinus and 
nasofrontal duct so that granulations would spring up and first 
occlude the narrowest part of the cavity, the bottom of the naso¬ 
frontal duct, then the remaining portion of the sinus. This 
author states the degree of deformity depends upon the size of 
the sinus. Ropke 448 further modified the operation by including 
the exenteration of the anterior ethmoidal cells in widely open¬ 
ing the floor of the frontal sinus. Drainage was made through 
the nose and the external wound usually closed. The cosmetic 
result of this operation was somewhat better than that of Kuhnt*s, 
as external drainage was abandoned. 

Jansen, 178 leaving the anterior wall intact, resected the infe¬ 
rior wall and exenterated the 'ethmoid labyrinth through this 
opening. The cosmetic result was not only not particularly satis¬ 
fying, but, on account of the spaces left in the cavity from the 
inability to reach all portions, recurrences were not uncommon. 
This author later modified the method by making medial and 
lateral cuts through the anterior wall, breaking it off high up and 


446. Kuhnt: fiber die entzundliche Erkrankungen d. Stirnhohlen, etc., S. 207, 1895. 
447. Coakley: The Frontal Sinus. Trans. Am. Lary. Assn., p. 226, 1905. 448. Ropke: 
Die Radikaloperation bei chronischen Eiterungen, etc. Arch. f. Laryng., Bd. 8, 1898. 



FRONTAL SINUS. 


281 


applying the bone-flap, together with the soft parts, to the pos¬ 
terior sinus wall. Healing was reported to occur in six weeks to 
six months . 449 

Riedel 450 removed not only the anterior but the inferior wall 
as well, thereby performing the most radical operation, from a 
surgical point of view, possible on the frontal sinus. As the soft 
parts of the forehead closed the cavity by coming into apposition 
with the cerebral wall, the entire sinus was thus obliterated. The 
operation, however, has one unsurmountable disadvantage—that 
of subsequent deformity, which can reach such proportions as to 
be hideously repulsive . 451 

Hartmann 452 removed not only the anterior wall of the sinus, 
but speaks of making an opening in the orbital wall through the 
ascending process of the superior maxilla. In this manner a 
partial bridge must have been made. 

Taptas , 453 of Constantinople, appears to have been the first one 
to suggest the advisability of making a bridge of bone across the 
supra-orbital ridge for the purpose of preventing the depression 
and deformity following the operation. Whether he had actually 
performed this operation on the living is not recorded. 

Killian , 454 "^ 56 however, was the first operator to develop and 
popularize this operation, which now bears his name. The pur¬ 
pose of the operation is to obliterate the sinus by allowing the 
peri-orbital tissues to ascend from below and to apply the skin 
and subcutaneous tissue originally in front to the posterior wall. 
In this manner one avoids a distinct disfiguration and at the same 
time is permitted to exenterate the ethmoid and sphenoid cells 
without danger of penetrating the cranial cavity. 

Technique: After all polyps and hypertrophies dependent 
upon the sinus suppuration have been removed from the nose and 
the size of the sinus ascertained by skiagraphy, anaesthesia is in¬ 
duced by chloroform. 

The nasal cavity of the affected side is plugged with four 
cotton tampons, about the size of a cigar, attached to threads. 


449 . Jansen: Neue Erfahrungen liber chronische Nebenhohleneiterungen der Nase. 
Arch. f. Ohrenhk., Bd. 56, S. 110 , 1902. 450 . Riedel: Schenke Inaugural Dissertation. 
Jena, 1898. 451 . Winckler: Beitrag zur osteoplastischen Freilegung des sinus Frontalis. 

Verh. deutsch Otol. Gesellsch., S. 128, 1904. 452 . Hartmann: Atlas der Anatomie der 

Stirnhohle, S. 25 , 1900. 453 . Taptas: Trans. Intematl. Med. Congress, Sec. on Laryn., 

1900. 454 . Killian and Krauss: Die Killiansche Operation chronischer Stirnhohlenen- 

terungen. Arch. f. Lary., Bd. 13, S. 28, 1902. 455 . Killian: Bemerkungen zur Radical- 
operation, etc. Verh. d. Vereins siiddeut. Lary., S. 21 , 1904. 456 . For complete descrip¬ 
tion in English, see Foster: Killian’s Frontal Sinus Operation. Detroit Med. Journ.,. 
Oct.-Nov., 1907. 



282 


THE ACCESSORY SINUSES OF THE NOSE. 



the eye. Several cross incisions are made in order to be able to 
approximate the wound accurately. 

Hemorrhage is arrested by haemostats, which are allowed to 
remain in place. Edges of wound retracted. The first periosteal 
incision at temporal end of original incision 6-8 mm. above and 
parallel to the supra-orbital margin. The second slightly internal 
to supra-orbital notch, extending downward through the centre 
of the ascending process of the superior maxillary. (Fig. 152.) 
The periosteum covering the frontal sinus above the bridge is 
elevated and retracted. A groove is made in the bone with ham¬ 
mer and Y-shaped chisel (Fig. 153), following the curve of the 
orbital margin until the sinus is penetrated. The lower surface 


The first one is placed on the nasal floor, the second in the middle 
nasal fossa, the third in the olfactory fissure, while the fourth is 
packed firmly along the internal bridge of the nose between the 
ascending process of the maxillary bone and the septum. This 
tampon supports the mucosa and pus, preventing injury during 
the resection of the bone. After the usual cleaning, the head being 
steadied, an incision, beginning at the temporal end of the eye¬ 
brow, is made inward through its middle to the nasal end, where 
it passes downward in a graceful curve along the side of the nose 
to the base of the nasal bone. (Fig. 151.) A gauze pad covers 


Fig. 151.—Line and extent of incision in the Killian 
operation on the frontal sinus. 


Fig. 152.—Two periosteal incisions. 1st, above 
the superior orbital rim with periosteum in place on 
the ridge. 2d, along internal orbital rim with peri¬ 
osteum retracted, thus exposing the lachrymal bone, 
lamina papyracea, and attachment of trochlea. 



FRONTAL SINUS. 


283 


of this groove forms the upper edge of the supra-orbital bridge. 

All of the anterior wall lying above the bridge is removed with 
bone forceps or chisel and mallet. After complete removal of 
the anterior wall, the mucous membrane, together with partial 
septa, is thoroughly curetted, especial care being given to all 
recesses and hollows; the bridge is smoothed oft and the sinus 
loosely packed with gauze. The resection of the ascending proc¬ 
ess of the maxillary bone is now undertaken, first elevating the 
periosteum from the frontal process, lachrymal fossa and orbital 
portion of frontal bone almost to supra-orbital notch. 

A groove is cut through the suture formed by the nasal bone and 
frontal process of superior maxillary in an upward direction by 
means of the curved V-shaped chisel. Another groove is made 
through the frontal process at right angles to the preceding, care 
being taken not to injure the lachrymal sac or the underlying nasal 
mucosa. (Fig. 154.) When necessary a third groove is made 
through the nasofrontal suture, forming the lower edge of the 



Fig. 153. —Killian’s V-shaped chisel. 


bridge. This is important, as otherwise the bridge could easily be 
destroyed in prying out the resected portion of the ascending 
maxillary process. 

A small opening is made at the junction of these grooves and 
the bone removed piecemeal so as not to lacerate the nasal mucosa, 
which is to form the flap leading into the frontal sinus. The 
extent of bone removed is governed by the size of the sinus, as it 
should extend well into the floor. The limits for the resection 
and elevation are: Below, lower part of lachrymal groove; behind, 
anterior ethmoidal vessels; above, trochlear attachment, supra¬ 
orbital notch. After the orbital tissues are retracted the ethmoid 
cells may be exenterated to the anterior wall of sphenoid. 

Reflected light will be necessary for this purpose. The resec¬ 
tion of the nasal mucosa beneath the resected frontal process, 
turning it into the sinus, completes the operation. (Fig. 155.) 
The wound is flushed out with normal salt solution, iodoform in¬ 
sufflated, and the edges are approximated with aluminum-bronze 
sutures. A gauze strip in the nose which extends upward holds 





284 


THE ACCESSORY SINUSES OF THE NOSE. 


the flap of mucosa in position. This strip is removed on the 
second day and the sutures on the fifth. 

The operation was immediately taken up by international 
operators with invariably good results, both from a curative and 
cosmetic standpoint. 457-460 It was, however, subject to one great 
drawback—that of the difficulty in technique (resecting maxillary 
process 1 without injuring mucosa and holding the trochlea in posi¬ 
tion, yet reaching the outermost recesses of the sinus). The time 
consumed (1 y 2 to 3 hours) in performing was also an important 
factor. Subsequent experience, 461-463 curiously enough, has taught 
us that the very eventualities which Killian so studiously endeav- 



Fig. 154.—Illustrating the grooves made in the 
ascending process of the superior maxillary and below 
lachrymal bone in order to resect this portion. 



Fig. 155.—Killian operation completed by 
turning flap of nasal mucosa outward. For¬ 
ceps in nares shows the w^de communication 
between the nose and the frontal sinus. 


ored to avoid did not occur, though, intentionally or otherwise, his 
technique was utterly disregarded. Thus it was found that the 
trochlea could he loosened from its position and retracted without 
fear of permanent diplopia, 464 provided that it was carefully brought 
hack to its original position on the completion of the operation. 
It was also noted that the careful resection of the ascending max- 


457. Von Eicken: Unsere Erfahrungen mit der Killianschen Stirnhohlenoperation. 
Verh. d. 1st Internat. Lary. Congress, Wien, S. 322, 1908. 458. F. L. Jack: Report of 
Four Cases Showing Result of Killian’s Operation. Journ. Am. Med. Assn., July 21, 1906. 
459. Logan Turner: The Operative Treatment of Chronic Suppuration in the Frontal 
Sinus. Edinburgh Med. Journ., March, p. 239, 1905. 460. Luc (231), p. 333. 461. Hajek: 
Lehrbuch, S. 224, 1909. 462. Mader: Beitrag. zur Killiansche Radicaloperation, etc. 
Arch. f. Lary., Bd. 20, S. 56, 1907. 463. Reichel: Bericht liber 60 nach Killian’s Methode 
ausgef. Stirnhohlen Ver. deutsch. Otal. Gesellsch., S. 115, 1907. 464. Eshweiler: On the 
Radical Operation for Chronic Empyema of the Frontal Sinus According to Killian. Arch, 
f. Otology, Oct., 1904. 





FRONTAL SINUS. 


285 


illary process to conserve the mucous flap was entirely super¬ 
fluous, as the cases did quite as well when the flap was either 
destroyed or lacking as when carefully packed in place. The 
omission of these steps very materially reduced the time of the 
procedure, and, together with other minor changes, the operation 
generally in use at the present time might well be termed the 
radical or modified Killian operation. 

Knapp's Operation. 465 — The technique of this procedure differs 
somewhat from that of Killian in the line of primary incision, as 
well as the extent of resection of the anterior wall. The intent 

is to procure better cosmetic re¬ 
sults so far as the depression is 
concerned. 

Technique: An external inci¬ 
sion is made along the upper 
orbital border midway between the 
eyebrow and the bony margin of 
the orbit, extending down along the 
inner wall and the side of the nose 
to the floor of the orbit. (Fig. 156.) 
The periosteum is incised at the 
orbital margin and with a sharp ele¬ 
vator retracted toward the orbit, 
gently detaching and pushing aside 
the soft parts and the lachrymal 
sac, thus exposing the internal wall and roof of the orbit. The 
pulley of the superior oblique is slowly detached from the trochlear 
fossa, care being taken not to disturb the relation between the 
tendonous ring and the periosteum to which it is adherent, so 
that during the process of healing it will assume its normal 
position. The floor of the frontal sinus is now removed and the 
diseased mucosa curetted. The nasal process of the superior 
maxilla, the lachrymal bone and a portion of the orbital plate of 
ethmoid are resected in order to gain access to the ethmoidal 
labyrinth and middle meatus. The removal of the ethmoidal cells 
is now accomplished with suitable forceps. 

If the frontal sinus extends unusually high up, a window is 
cut in the anterior bony wall, leaving a broad supra-orbital margin 
of hone covered with periosteum. This should he only of sufficient 

465. Knapp: The Surgical Treatment of Orbital Complications in Diseases of the 
Nasal Accessory Sinuses. Journ. Am. Med. Association, July 25, 1908. 





286 


THE ACCESSORY SINUSES OF THE NOSE. 


size to allow proper treatment of the superior margins of the 
sinus, thus avoiding subsequent deformity. Suture of the cuta¬ 
neous wound is not practised, and external drainage is made by 
a gauze strip into the sinus at the internal angle of the wound. 
The ethmoidal region is lightly packed through the nose. 

Radical or Modified Killian Operation.— Technique: Pre¬ 
liminary steps before anesthetization • 

Bind up hair securely with sterile towel. Wash out nasal 
cavity thoroughly with warm normal salt solution. Cleanse fore¬ 
head, eyebrows and lids with bichloride of mercury 1-5000, fol¬ 
lowed by alcohol, and cover with wet compress of alcohol and 
water. Give hypodermic of morphia sulph. gr. %, atrophia gr. 
1/150. Trim eyebrow. 

The question of shaving the eyebrow on the side to be operated upon depends 
upon the operator. It seems, however, to be the general experience that when the 
eyebrow is shaven it is by no means certain whether it will again grow in or 
whether it will come in so heavy as to be out of all proportion to its fellow. Under 
these circumstances, it is better to thoroughly disinfect and leave in situ. 

Anaesthesia with ether. Pack nose with long strip of sterile 
gauze, seeing that the end is introduced well within the clioana 
to absorb the blood from anterior sphenoidal wall. 

Killian 468 uses four tampons about the size of small cigars, which are intro¬ 
duced, first between inferior turbinate and septum, the second high into middle 
nasal passage, the third into the olfactory fissure and the fourth along the anterior 
angle of the nose. These are fastened to threads which hang out of the nose. It 
is not necessary to use all these tampons, as one long strip of gauze inserted well 
posteriorly, completely closing the nares, will answer the purpose quite as well. 

Make curved incision through the eyebrow around side of nose 
ending at a point on the middle of the ascending process of supe¬ 
rior maxilla opposite the inferior portion of the lachrymal bone. 
On the right side the incision should be started at the eyebrow 
and carried downward and on the left side from the cheek up¬ 
ward. (Fig. 157.) This incision is carried down to, but not 
through, the periosteum. A half dozen or more hsemostats must 
be in readiness, as the bleeding will be profuse. Nothing further 
should be attempted until the hemorrhage is completely con¬ 
trolled, a procedure which will require a delay of one or two 
minutes. No ligatures are to be used, as they may later super¬ 
induce secondary infection. The eye is covered with a pad of 
gauze, to prevent undue pressure from the haemostats. 


466. Killian (455), S. 24. 







FRONTAL SINUS. 


287 


The overlying soft parts are now dissected away from the 
periosteum both above and below the attachment of the lachrymal 
bone with the ascending process of the superior maxilla. The 
periosteum is now incised along the orbital edge and elevated for 
a space of one or two centimetres. (Fig. 158.) 

A small, half-round chisel is used to open the frontal sinus, 
there being two points of predilection. 

1. Below the supra-orbital ridge immediately above the lach¬ 
rymal bone, and 2. Above the supra-orbital ridge immediately 
above the frontal articulation of the superior maxillary. 



Fig. 157.—1st step. Skin incision for the modified 
Killian operation on the frontal sinus. 


Fig. 158.—2d step. Incision in the periosteum 
above the supra-orbital rim showing point of elec¬ 
tion for entering the sinus. 


Both positions are practically certain to strike the sinus, but the 
second is easier and should perhaps be preferred, especially 
when one has ascertained the exact size of the cavity by means of 
an X-ray photograph,—a preliminary procedure which should 
always be applied. After the chisel has penetrated into the sinus, 
a bent probe is introduced and carried in all directions so that its 
various dimensions may he ascertained. The periosteum is now 
incised about a half inch above the superior edge of the orbital 
ring and carried outward slightly further than the external con¬ 
fines of the sinus and inward and downward the length of the 
original external incision, but sufficiently internal to alloy the 
formation of the bony bridge. (Fig. 159.) 



288 


THE ACCESSORY SINUSES OF THE NOSE. 


This periosteal incision is somewhat important, as one must allow for a 
certain amount of laceration during the course of the operation, therefore it is 
better to allow too much in the first place. The redundancy can be used to cover 
the superior surface of the bony ridge, thus further insuring good blood supply to 
this structure. 

Again using the elevator, the periosteum is raised in all direc¬ 
tions slightly beyond the sinus borders, leaving untouched that 
portion which covers the part of the wall which will ultimately 
form the supra-orbital bone bridge except to loosen it slightly at 



Fig. 159.—3d step. Upper periosteal incision. 


Fig. 160.—4th step. Periosteum elevated above 
and groove made in bone for the superior edge of the 
bony bridge. 



the superior edge in order to avoid wounding when the prelim¬ 
inary groove for the ridge is made. The soft parts, including 
periosteum, being retracted and held by an assistant, the angular 
chisel is now used to make a f urrow along the line which will form 
the superior border of the bridge. This is accomplished by plac¬ 
ing the point of the instrument at the external limit of the sinus 
about one-half inch above the orbital rim, and, by carefully tap¬ 
ping with the hammer, cutting a shallow furrow reaching down to 
the superior articulation of the nasal bone, always following and 
keeping a like distance from the curve of the orbital rim. 
(Fig. 160.) 






FRONTAL SINUS. 289 

?! e11 in the beginning to preserve more bone than will actually be needed 
tor tiie bridge, as the supra-orbital notch may encroach considerably on the superior 
cut, making that portion exceedingly weak and liable to fracture on application 
of the slightest force. If an insufficient amount of osseous structure is left the 
bridge will be liable to any future traumatism, while if one finds that too much 
bone remains, it can easily be reduced at the conclusion of the operation. The 
width of the completed bridge should be at least 5 mm. 

This furrow is gradually enlarged until a long slit is made into 
the sinus. The entire anterior wall above this cut is now removed 



Fig. 161.—Alexander’s hollow chisel. 


piecemeal with larger chisels (Fig. 161), rongeurs (Fig. 162), or 
other suitable instruments until the sinus is completely bared, 
particular attention being paid to open all ramifications in their 
fullest extent, as when a relapse occurs, these are the points of 
origin. (Fig. 163.) 

The diseased portion of the sinus mucosa is now removed with 
the curette, care being taken to minutely inspect the underlying 
bone for any traces of necrosis. After controlling hemorrhage 
the inferior wall is removed in the following manner: The per- 



Fig. 162.—Bone cutting forceps for removing the anterior wall of the frontal sinus. 

iosteum is incised at the internal angular edge of the orbital 
ridge, the cut being carried downward to the lower part of the 
attachment of the lachrymal bone with the ascending process of 
the superior maxillary. (Fig. 164.) An elevator is then introduced 
and the periosteum, together with the attachment of the superior 
oblique and trochlear nerve, is raised and pushed over the orbital 
fat. Below, the lachrymal duct is raised from its fossa with the 
periosteum lying over the anterior third of the lamina papyracea. 
The internal and superior part of the orbital socket is thus laid 
bare at least in its anterior portion. (Fig. 165.) Considerable 
hemorrhage often follows this procedure, as the ethmoidal vessels 

19 










290 THE ACCESSORY SINUSES OF THE NOSE. 

are usually injured. Packings of iodoform gauze, which are 
allowed to remain some moments in place, will control the bleed¬ 
ing. After this has been accomplished the sharp angle chisel is 


placed at the superior internal angle of the orbit beneath the sinus 
floor, and an opening made sufficiently large to permit the introduc¬ 
tion of a pair of bone forceps (Jansen’s model). The floor is care- 


Fig. 163.—5th step. . The entire anterior wall of the 
sinus removed. 


Fig. 164.—6th step. Lower periosteal incision 
extending along the supra-orbital rim. 


Fig. 165.—7th step. The soft tissues elevated. Fig. 166.—8th step. The entire floor of the sinus 
exposing the floor of the sinus, ascending process of removed, 

superior maxillary, lachrymal bone, and lamina 
papyracea. 








FRONTAL SINUS. 


291 


fully removed, using a straight chisel when nearing the osseous 
bridge in order to incur no danger of breaking it, until the cavity is 
absolutely without an inferior wall. (Fig. 166.) 

It is now necessary to remove a portion of the ascending max¬ 
illary process in order to reach the infundibular cells and have 
free access to the bulla and middle turbinate. After elevating the 
periosteum, taking care not to denude the bridge, two horizontal 
furrows are made in the ascending process opposite and anterior 
to the lachrymal bone. (Fig. 167.) A large concave chisel is now 
taken and the bone removed between the furrows, thus laying bare 
the anterior ethmoidal structures. (Fig. 168.) 



Fig. 167.—9th step. Rectangular groove cut in the 
ascending process of superior maxillary. 



• £* G - 10th step. Bony flap resected together 

with anterior (infundibular) ethmoid cells, exposing the 
middle turbinate and bulla. 6 


It is not necessary to preserve the underlying: nasal mucosa in order to make 
the flap as formerly advocated by Killian, as results have proved to be quite as 
good when this plastic formation was omitted. 

The superior portion of the lachrymal bone is now removed 
with the forceps, and the bulla and entire anterior ethmoidal 
labyrinth exenterated back to the lamella of the middle turbinate. 

If the posterior ethmoid cells and sphenoid sinus be diseased it is a simple 
matter to continue removing the ethmoid cells until the anterior wall of sphenoid 
is reached. To open this sinus it will only be necessary to remove its wall. 

At this point it may be necessary to enlarge the opening ante¬ 
riorly in order to procure sufficient drainage from the frontal. 
For this purpose the anterior superior nasal spine may be re- 




292 


THE ACCESSORY SINUSES OF THE NOSE. 


moved with the bayonet chisel. The gauze packing is removed 
from the nose and a pair of forceps introduced in the direction 
of the frontal sinus in order to ascertain whether the communi¬ 
cation is sufficiently extensive. Such being the case, the entire 
wound is thoroughly flushed out with sterile saline solution, a strip 
of seamed iodoform gauze introduced into the sinus through the 
nose (Fig. 169a), and the external wound closed with silkworm-gut 
sutures, except at a small portion corresponding to the internal 
angle of the eye, in which a small drain is placed. (Fig. 169b.) 

Primary closure of ftke entire wound should only be made when the sinus is 
very small. Under ordinary circumstances a small drain is allowed to remain 
in place for two days. If the sinus extends considerably toward the temporal 
bone, a drain should be placed at the external end of the wound. The presence of 
acute inflammatory processes, meningeal or ophthalmic complications demand that 
the wound remain open and secondary sutures only applied after these symptoms 
have entirely disappeared. Under the latter circumstances daily dressings of humid 
bichloride gauze should be applied. 

The face is dried and iodoform dusted on the wound. Rolled 
gauze compresses are placed above the bony ridge and inter¬ 
nally along the eye, several thicknesses of loose gauze over these 
and a firm bandage embracing the eye on the opposite side 
being applied. 

Killian applies moist boric acid gauze dressings. 

After-treatment: 467 The patient should lie on the sound side 
and not be permitted to blow the nose, as it might prevent the 
walls from adhering and cause a permanent pneumocele of the 
frontal sinus. Secretion which forms in the nose must be drawn 
into the choana and expectorated. The drain through the nose 
into the sinus may be removed after twenty-four hours or forty- 
eight hours. 

The day following the operation, the bandage should be removed 
and the pads over the eye and wound renewed as they are usually 
saturated with blood and dried, thus being capable of causing 
injury to the eye if permitted to remain in place. 

Unless untoward symptoms develop (fever over 100°, severe 
headache, etc.), the dressing should not be changed until the third 
day, when it is necessary to remove gauze under antiseptic pre¬ 
cautions, sponge wound with bichloride 1-5000 and remove drain 
from internal angle of wound. A few drops of thin pus can 
usually be pressed out, after which the opening is gently irrigated 
so as not to force apart the anterior wall, and a new iodoform 

467. Luc: Treatment after Radical Operation for Chronic Suppurative Frontal 
Antritis. Ann. Otol., Rhin. and Lary., Dec., p. 963, 1906. 




Fig. 169a. — 11th step. Seamed iodoform gauze 
carried through the nose into the sinus. 


. Fig. 1696.—12th step. A gauze drain is placed 
in the internal angle of the incision and the wound 
closed with silkworm-gut sutures, thus completing 
the operation. 
























































































































































































































































































FRONTAL SINUS. 


293 


drain reintroduced. This is continued every second day until 
healing is established. The stitches can be removed any time after 
the fourth day, according to the appearance of the wound. 

Osteoplastic Resection . 468 469 — This form of operation con¬ 
sists in turning back a flap of bone with the soft parts from the 
anterior wall of the frontal sinus, curetting the interior, enlarg¬ 
ing the nasofrontal duct, closing the wound by bringing the fl&p 
again in apposition. 

For cosmetic purposes this method is unexcelled, but is very 
unreliable on account of the many recurrences of the disease after 
its application, due to the dead spaces within the sinus. It is only 
indicated when the sinus is perfectly formed without projec¬ 
tions, where the anterior wall may be completely turned back. 
Involvement of the osseous walls as well as the presence of cere¬ 
bral or orbital complications are strong contra-indications. 

Technique: An incision is made from the inner to the outer end 
of the eyebrow along its inferior border to obviate any deformity 
from an irregular position of the brow in the scar formation. The 
incision is carried through the soft parts and periosteum at least 
0.5 cm. from the orbital border. A perpendicular incision begin¬ 
ning at the nasal end of the previous cut is now made, reaching 
above to the superior limits of the sinus (the extent of the cavity 
must have been ascertained by an X-ray photograph). This inci¬ 
sion should not extend straight upwards, but conform to the posi¬ 
tion of the intersinus septum and lie slightly outside the sinus 
boundary, where the bone will be chiselled, thus preventing depres¬ 
sion of the scar. The periosteum is elevated away from the sinus, 
i.e., downward over the supra-orbital ridges and medialward, thus 
avoiding any interference with the soft parts immediately over- 
lying the anterior sinus wall. A small opening is now made at the 
deepest portion of the anterior sinus wall by means of a small 
concave chisel. After the limits of the sinus have been verified by 
the sound the bone is chiselled through in a horizontal and vertical 
direction, keeping as close as possible to the sinus borders. A 
stout elevator is forced into the sinus through the original opening, 
and the flap pried strongly upward until it fractures at its base. 
(Fig. 170.) If this does not readily occur owing to the thickness of 
the bone, some of the basal edges may be removed. The flap of 
bone and soft tissues is now turned back and the interior of the 

468. Winckler (451). 469. Hoffman: Osteoplastic Operations on the Frontal Sinuses 
for Chronic Suppuration. Ann. O., R. and L., p. 598, 1904. 



294 


THE ACCESSORY SINUSES OF THE NOSE. 


sinus curetted of all diseased tissue, including ridges and partial 
septa. The nasofrontal duct being scraped is enlarged by re¬ 
moving the anterior superior nasal spine by means of a chisel. A 
large drainage tube is introduced which is allowed to remain in situ 
from six to twelve weeks. It is held in position by a suture through 
the skin. The flap is brought into position and the wound closed 
by primary sutures, the bandage being allowed to remain undis¬ 
turbed for a week to ten days, unless untoward symptoms super¬ 
vene. No after-treatment is required, except to keep the 

nasal end of the tube free from 
crusts. Irrigation in any form is 
not used. 

In order that this operation 
succeed, the following conditions 
are imperative: 

1. The bone-flap must rest 
everywhere on the surrounding 
bone. 

2. All recesses and granular 
tissue in the sinus must have been 
obliterated. 

3. The flap must be well sup¬ 
plied with periosteum. 

4. A wide connection between 
the nose and sinus must be 
established. 

Lothrop 's Operation. 469 a> b > c — 
Preliminary to the external procedure, the front of the middle 
turbinate and anterior ethmoid cells are removed. 

1. An incision is made similar to the Killian except not extend¬ 
ing as far downward and outward. (Fig. 170a.) 

2. An area of bone directly above and below the incision is de¬ 
nuded of periosteum and the sinus entered just above the base of 
the nasal process. (Fig. 1706.) 

3. The sinus is cleared of inflammatory tissue, the periosteum, 
however, not being removed, and the cavity explored with a probe 
to determine the location of the ostium and the probe passed 
downward into the nose and out the anterior nares. (Fig. 170c.) 

4. The ostium is gradually enlarged by small curettes and burr 

469a. Lothrop: Frontal Sinus Suppuration. Ann. of Surgery, June, 1914. 469b. 

Lothrop: Frontal Sinus Suppuration With Results of New Operative Procedure. Journ. 
Am. Med. Assn. July 10, 1915. 469c. Lothrop: Treatment of Frontal Sinus Suppuration. 
Laryngoscope, p. 1, 1917. 










Fig. 170 d .—Aspect of lateral wall. 



Fig. 170c. —Probe passed through sinus emerging from 


nose. 



Fig. 170e.—Aspect of septal wall. 


























































- 


















































. 




































Jr 

























FRONTAL SINUS. 


295 


drills but only from behind forward, thus avoiding the cribri¬ 
form plate. 

5. A small burr is introduced through the nose and the anterior 
superior nasal process attacked cutting toward the nasal bone and 
nasal process at about their upper suture line, larger size burrs 
being gradually substituted. 

6. The remaining ethmoid cells around the infundibulum, 
lachrymal bone and agger nasi are broken down and removed. 
(Fig. 170d.) ' 

7. A large part of the inter-frontal septum is now removed, 
also that portion of the nasal septum just below the sinuses, to the 
depth of about one inch. (Fig. 170e.) 

8. External wound closed, without drain and compress bandage 
applied. Irrigation is to be avoided for several days. 

This operation is to all intents and purposes a Halle (p. 272), 
performed by the external route. It has several disadvantages from 
the rhinological viewpoint, that of opening up a healthy sinus, and 
the unnecessary removal of a portion of the nasal septum. 

Beck’s Method of Osteoplastic Resection . 470 —The exact size 
of the sinus is ascertained by means of the radiogram and traced 
on a celluloid film. At the time of the operation this is used as a 
model and both sinuses opened by sawing off their anterior walls 
with a Gigli saw. The flap is sawn through at the base and turned 
downward. Removal of the diseased mucosa, enlarging the natural 
opening into the nose with the introduction of a large trephine and 
final replacement of the osseous flap completes the operation. 

1. An incision isi made through both eyebrows, which is carried across the 
bridge of the nose at a point lower down. 

2. The skin and subcutaneous tissue are now dissected upwards until the upper 
limits of the frontal sinuses are reached. 

3. The celluloid tracing is placed over the sinuses and the periosteum incised 
around the upper and lateral margins, but not below over the supra-orbital borders 
or base. 

4. The external table of the sinus is penetrated along the entire course of the 
periosteal incision by means of a flat chisel. 

5. The flap is slightly pried open and a Gigli saw drawn from within outward 
so as to sever the bone but not the periosteum. The skin flap is reflected upward and 
the periosteal bone flap downward, thus exposing both frontal sinuses (Fig. 171). 

6. The diseased mucosa is thoroughly eradicated and the natural opening into the 
nose enlarged with trephine or rasp. The infundibular cells are also exenterated. 

7. A rubber tube containing a wick is passed through into the nose and one 
end of the wicking loosely folded within the cavity of the sinus, the other end pro¬ 
trudes into the nose. 

470. Beck: A New Method of External Frontal Sinus Operation without Deformity. 
Journ. Am. Med. Assoc., Aug. 8, 1908. 



296 


THE ACCESSORY SINUSES OF THE NOSE. 


8. Replace osteoplastic flap, bring down skin-flap and suture with silkworm 
gut. The gauze is removed the next day and the third to fifth days the rubber tube is 
replaced by one of silver or gold. The use of douches is to be avoided. 

Watson Williams Osteoplastic Method. 471 —An incision is made through 
the eyebrow to the root of the nose, then downwards along the side of the nose, just 
outside the median line. The soft tissues with the periosteum are elevated over 
the anterior wall of the sinus, and the bone removed to within 3 or 4 mm. of the 
floor. A second incision, about three-quarters inch in length, is now made along the 
inferior and internal margin of the orbit, exposing the lachrymal groove. The 
lachrymal duct is elevated and retracted, and by means of a chisel, entrance is made 
into the nose. A fine saw is passed intoi the nose and divides the nasal process of 

superior maxillary through 
this opening. A second 
saw-cut is now made from 
the frontal sinus to the 
lachrymal fossa from be¬ 
hind forwards so as to 
leave the soft tissues intact. 
The saw is now placed at 
the inner portion of the 
frontal sinus and the bone 
divided along the bridge of 
the nose until the nasal 
bones are cut through. The 
osteoplastic flap is now 
turned out, allowing free 
access to the frontonasal 
passage. The interior eth¬ 
moid cells can now be re¬ 
moved and, if necessary, 
the sphenoid sinus pene¬ 
trated. The mucosa of the 
frontal sinus is curetted, 

ridges removed and the flap replaced and sutured. 

Citelli's Method. 472 —This is really a modification of Coakley’s open method 473 
and consists in removal of the anterior walls of the sinus, with thorough curettage 
of the mucosa, followed by secondary obliteration by means of Mosetig’s paste 
mixture. 

The entire anterior wall of the frontal sinus is removed so that all recesses and 
hollows, together with the anterior ethmoidal cells, can be reached. The sinus and 
nasofrontal duct are curetted and thoroughly disinfected. The cavity is allowed to 
remain open and is daily irrigated with 1/3000 formalin solution and cauterized, 
especially in the neighborhood of the nasofrontal duct, with chloride of zinc. The 
cavity is then packed with iodoform gauze. This treatment is continued for two to 
four weeks until the communication between the nose and frontal sinus is completely 
occluded with connective tissue and the walls of the sinus are covered with extensive 
healthy granulations. 

When these granulations have formed the sinus is thoroughly disinfected with 
the formalin solution, followed by peroxide of hydrogen. The walls are now dried 
with sterile gauze and cotton, and finally with very hot air from a specially con¬ 
structed apparatus. 

471. Williams: Discus, to V. Eichen. Trans. 1st Int. Laryng.-Rhinol. Congress, Vienna, 
p. 333, 1908. 472. Citelli: Ueber meine methode, etc. Zeit. f. Lary., Bd. 2, S. 339, 1910 
473. Coakley (360), p. 457. 



Fig. 171. —Beck’s method of osteoplastic resection of the frontal 
sinus. The skin and underlying tissues have been retracted upwards. 
The bone flap resected and luxated downwards, exposing the diseased 
sinus on the left. The right frontal sinus is healthy. 





FRONTAL SINUS. 


297 


Sterilized Mosetig’s mixture (Sesame oil and Spermoid aa 40.0, Iodoform 60) 
is slowly poured into the sinus until full, and the wound closed with stitches. 

According to Citelli, this method is particularly to be recommended in small 
sinuses and in young people, and is preferable to Coakley’s, as the duration of heal¬ 
ing is greatly shortened. Little or no deformity remains, as the infused material is 
quickly replaced by newly formed connective tissue. 

Engelhardt, 4733, however, does not appear to have had the same results, and 
points out the disadvantages of plugging the sinus according to this method. 


COMPARISON OF METHODS. 474 

The simple trephination through the anterior wall is seldom 
practised for a curative procedure, but under certain conditions 
may be of great value, especially when an extensive operation is 
not advisable. Perhaps the strongest indication for a small 
external opening is in symptoms of retention during an acute 
attack, when all intranasal attempts at drainage have failed. 
Cure in these cases follows almost immediately. For purposes 
of diagnosis in chronic conditions- trephination is also of value 
and, indeed, it is always the first step in any radical procedure on 
the frontal sinus. 

The Ogston-Luc Operation. —During the later 80’s and early 
90’s probably no operation was more generally accepted and per¬ 
formed on the frontal sinus than this one. The results, however, 
were far from ideal either in a curative or cosmetic sense. 475-477 
The reason for these failures lay in the fact that all portions of 
the sinus could not be reached by the operation and on this account 
the procedure has been superseded by the newer methods. 478 The 
dangers of this operation are also not inconsiderable, as Boen- 
ninghausi 479 has collected fifteen deaths from intracranial compli¬ 
cations which were the direct result of this procedure. 

Kuhnt's Method for Obliterating the Sinus.— The results 
obtained from a curative viewpoint by this method were excel¬ 
lent; 480 the great drawback, however, was the deformity and the 

473a. Engelhardt: Empfiehlt sich die Plombierung der Stirnhohle nach Citelli. Med. 
Klinik, Aug. 18,1912. 474. Cobb: Empyema of the Frontal Sinus. (Comparison of Meth¬ 
ods.) Boston Med. andSurg. Journal, Aug. 24,1905. 475. Lermoyez: 17 cases—9 cured—8 
relapsed. Indicat. et Resultatdu Traitementdessin. max. et frontales. Ann. des Mai., etc., 
Nov., p. 436,1902. 476. Lack: 11 cases—11 relapses. Treatment of Chronic Suppuration in 
the Frontal Sinus. Edinburgh Med. Journ., vol. 11, p. 542, 1902. 477. Turner: 10 cases 
—6 cured—4 relapsed. The Operative Treatment of Chronic Suppuration of the Frontal 
Sinus. Trans. Am. Med. Assn., Sec. on Lary., p. 303,1904. 478. Mermod (Arch. Inter, de 
Lary., vol. 20, p. 51, 1905), however, gives the astonishing number of 165 cures in 165 
cases. 479. Boenninghaus: Handbuch der speciellen chirurgie des ohres, etc. Katz, 
Preysing and Blumenfeld, Bd. 3, S. 171, 1911. 480. Boenninghaus (479), S. 177, collected 
101 cases from various operators, with 99 cures. 



298 


THE ACCESSORY SINUSES OF THE NOSE. 


length of time of post-operative treatment required for healing. 
Jansen’s method of resecting only the inferior wall proved a fail¬ 
ure from every point of view, even the author finally admitting 
its limitations. Ritter 481 practised a modification of this method 
by resecting also the frontal process of the superior maxillary, 
and in large sinuses placing a counteropening in the anterior wall. 
The cosmetic results have been uniformly excellent, and the mor¬ 
tality one death from meningitis in twelve operations. This 
method, to all intents and purposes, is identical with that of 
Knapp, 465 and can he well applied in those cases where the sinus 
runs backward over the orbit, but not high anteriorly. 

Riedel’s operation in which complete obliteration of the sinus 
is obtained by resecting everything except the posterior wall is 
the most radical and at the same time the most disfiguring of all 
the external operations. At first sight it would seem to be never 
indicated, but under certain circumstances it is distinctly the 
operation of choice. In old people whose constitutions would not 
stand the shock of a prolonged surgical intervention, the ensuing 
deformity makes little difference and the rapidity with which the 
operation can be completed doubly predisposes in its favor. 
Necrosis and caries of the walls sometimes make the formation 
of a bridge impossible; this method is then demanded. When 
both sinuses are diseased and a double intervention is required, 
the Riedel operation has been applied with the best cosmetic 
results. 482 

Coakley’s method of obliterating the sinus secures permanent 
cures with a very low mortality.* * The great disadvantage is the 
long period of after-treatment while the sinus is being filled with 
granulations. 

Killian’s Method.— This form of operation, with minor modi¬ 
fications, is the one generally in use at the present time. The 
original procedure, which avoids disturbing the trochlea or pulley 
of superior oblique, has now been abandoned by Killian, as it re¬ 
quired an immense sacrifice of time and was found to he unneces¬ 
sary, as the functions of the eye underwent no permanent 
disturbances (see p. 283). 

This author gives the following indications for his method : 483 


481. Ritter: Die Erhaltung der vorderen Stimhohlenwand bei der radikal Operation. 
Verh d. ver deutsch. Lary, S. 196, 1911. 482. Kuile: Ueber doppelseitige Stirnhohlen 

operation und deren asthetischen Effekt. Zeitschr. f. Laryn., Bd. 1 S 645 1909 483 

Killian (455), S. 23. 

* Coakley (355) reports 101 absolute cures in 104 cases. 




FRONTAL SINUS. 


299 


1. When other forms of operation have failed. 

2. The appearance of a fistula, abscess, or necrosis. 

3. When symptoms of intracranial complications appear. 

4. When, during the course of a chronic frontal sinusitis, pain 
and fever suddenly appear and the discharge becomes fetid. 

5. When the headache referred to the eye is not influenced by 
intranasal procedures. 

6. When the discharge remains fetid despite frequent irriga¬ 
tions. 

7. When the sinus inflammation gives rise to recurrent poly¬ 
poid hypertrophies and polyp formations. 

8. When a simple purulent discharge is not relieved by intra¬ 
nasal measures and the patient is anxious to procure permanent 
relief from his annoying symptoms. 

The osteoplastic resection as practised by Hoffman may be 
used in carefully-selected cases in which the sinus is regular. It 
is particularly indicated in actors, preachers, lecturers, and 
teachers, whose profession requires them to be constantly before 
the public, as the cosmetic results far surpass those of any other 
method. The danger of recurrence does not lie so much with the 
headache and symptoms of occlusion and retention as those of a 
constant seepage from the nose, due to the formation of granulations 
within the sinus which do not become covered with epithelium. 
External fistula formation is of the greatest rarity. 

Beck’s method has not only the disadvantage of opening a 
sound sinus, but requires* great technical skill and has the same 
chance for recurrence as the ordinary resection. 

Watson Williams’s operation is perhaps the most extensive and 
difficult of all the osteoplastic measures. As it seems to be directly 
intended to maintain the position of the tendon of the superior 
oblique, and as this is now known to be unnecessary, the main proced¬ 
ure would seem to have lost its purpose, and the same results can be 
obtained much more easily by using the ordinary radical method. 

Untoward Results Following the Killian Radical Operation . 483a 
—Occasionally, in spite of every precaution in technique and 
asepsis, untoward sequelae appear, which may only be evanescent 
or may lead on to fatal consequences. 

(a) (Edema of the TOper Eyelid: This swelling practically 
always appears on the second or third day following this opera- 

483a. R. H. Skillern: Untoward Results Following the External Operation on the 
Frontal Sinus. A Critical Review of Twenty Cases. Laryngoscope, p. 1063, 1913. 



300 


THE ACCESSORY SINUSES OF THE NOSE. 


tion, often being so marked as to tightly close the eye. As a rule, 
absorption will take place slowly under moist boric acid dress¬ 
ings, but it frequently requires several weeks before the lid re¬ 
sumes its normal appearance and function. If the oedema is due 
to an accumulation in the sinus it will be necessary to insert a 
probe through the wound, thus permitting its escape, otherwise 
general suppuration of the tissue may supervene. To avoid these 
cedematous swellings, the eye should receive the greatest care dur¬ 
ing the operation by keeping it covered with a gauze pad to prevent 
pressure from hsemostats, and especially not to apply unnecessary 
force during retraction. 

(b) Diplopia due to the dislocation of the tendon of the superior 
oblique is not an infrequent symptom immediately after the opera¬ 
tion . 484 The condition gradually disappears after a few days, unless 
permanent injury has been done. Permanent diplopia following 
the modified Killian operation appears to be of great rarity. 

Hajek, 485 in 10 cases in which the trochlea was resected, did not have permanent 
diplopia in a single instance. 

Killian, 486 in 106 cases, observed diplopia in only five cases, four after four 
weeks, and one after ten months. 

Kahler, 486 in 30 cases, observed one case of permanent diplopia. 

Siebenmann, 487 —none in 34 cases. 

Ritter 488 reports three cases of persistent diplopia and recommends stitching the 
trochlea to the periosteum of the supra-orbital ridge at the end of the operation. 
The author has had two cases which have persisted over one and two years re¬ 
spectively. The double vision is more apparent in the lower fields when the patients 
look downward. The condition in both has been relieved by wearing appropriate 
glasses and in one case appears to be disappearing. The trouble in the first case is 
undoubtedly due to the tendon of the superior oblique becoming -involved in the scar 
tissue, as the diplopia did not manifest itself until several weeks after the operation. 

(c) Pneumatocele 489 over the sinus: This occurs when the an¬ 
terior flap has not adhered to the posterior sinus wall, and is due 
to the patient forcibly blowing the nose, thus loosening the tissues 
by inflation. The best means of preventing this is to apply a roll 
of gauze over this portion at each dressing and hold it firmly in 
place by the bandage until adhesion has taken place. 

(d) Anaesthesia of forehead over area supplied by the supra¬ 
orbital nerve. It is, of course, impossible to avoid this occurrence, 
as the nerve must be divided. As time gradually wears on, sen- 

484. Bousseau: De la paralysie de grand oblique dans les operations sur le sinus par 
voie frontale. Arch. Internat. de Laryng., T. 31, p. 640, 1911. 485. Hajek: Ueber Indi- 
kationen zue operat. Behandl. bei der chron. Stirnhohlenentzundung. Wien. med. Woch- 
enschr., June 27, S. 1466, 1908. 486. Killian, Kahler, Ritter: Verh. 1st internat. Larv. 
Kongress, S. 332, 336, 1909. 487. Siebenmann: Zeitschr. f. Ohrenhk., Bd. 61, S. 353, 1910. 

488. Ritter: Kosmetische Stirnhohlenoperationen. Zeit. f. Lary., Bd. 5, S. 30, 1912. 

489. Levinger: Pneumocele des Sinus Frontalis. Arch. f. Lary., Bd. 19, S. 528, 1907. 



FRONTAL SINUS. 


301 



sation slowly appears, until the parts become supplied by collateral 
branches or the main trunk reunites. 

( e) Supra-orbital neuralgia sometimes appears, due to the in¬ 
volvement of the end of the nerve in the fibrous tissue formation of 
the scar. Under such circumstances a resection of the nerve is 
required; therefore, to avoid a second intervention, many operators 
resect a portion of the nerve at the time of the original operation. 490 

(/) Stitch abscess: Undoubtedly, many fatal cases have orig¬ 
inated from one of these abscesses. The parts, being completely 
closed by sutures, are in favorable condition for secondary infec¬ 
tion, which goes on to meningitis and death. On this account most 
operators abstain from complete closure of the wound without ex¬ 
ternal drainage, and allow the internal inferior margin of the inci¬ 
sion to remain open for forty-eight hours. In cerebral or orbital 
complications of any sort the entire cavity is packed with iodoform 
gauze; no sutures are applied until after the fourth or fifth day. 

In case of a stitch abscess occurring, the suture must be removed 
and the wound thoroughly irrigated with 50 per cent, solution of 
euthymol in water and a small gauze drain inserted. 

(g) Blindness on the operated side has been reported, 491 ’ 492 
being due either to injury to the optic nerve or to the lengthy 
pressure of the blood-soaked and hardened dressing. One case 
occurred in my practice 483a the cause of which was never apparent. 
Nothing unusual presented itself during the operation, nevertheless 
the optic nerve must have become injured. This can only be ex¬ 
plained by either fracture of the lamina papyracea into the optic 
foramen or a dehiscence in the superior wall of sphenoid, the sheath 
of the nerve being injured when the sphenoid sinus was opened. 

(h) Osteomyelitis: Postoperative osteomyelitis does not appear 
to be infrequent, judging from numerous reports of cases from all 
sides, 493 ’ 494 but, fortunately, every case does not go to fatal ter¬ 
mination, as the disease may become localized in a portion of the 
frontal bone. 494a On the other hand, the entire table of the cranium 
can become necrosed, as is illustrated in the well-known case re¬ 
ported by Tilley. 495 

The only precaution possible against this occurrence while oper- 

490. Laurens: Chirurgie du Sinus Frontal. Ann. des mal. de l’oreille, T. 1, p. 521, 
1904. 491. Kanapp: Cecite consecutive a l’operation d’une Emphyseme du sinus frontal. 
Annal d’ocul., T. 126, p. 67, 1901. 492. Freudenthal (354). 493. Sieur et Louvillois: 

Traitement chirurgical des Antrites Frontales Etude critique des accidents consecutifs 
(osteomyelite). Arch. Internat. de Laryng., Med. T. 31, p. 733, 1911. 494. Luc (42). 
494a. Tilley: Acute Osteo-myelitis of the Frontal Bone. Operation; Recovery. Brit. 
Med. Journ., July 7, 1917. 495. Tilley: Reported at the meeting of the Brit. Assn., m 


Portsmouth, 1899. 






302 


THE ACCESSORY SINUSES OF THE NOSE. 


ating is to keep the raw edge of the bone as sterile as possible by 
frequent applications of gauze moistened with bichloride of mer¬ 
cury, and, in curetting the sinus, avoid opening up the lymph- 
channels in the bone. 

(i) Meningitis: Suppurative inflammation of the meninges ap¬ 
pears to have resulted from operations on the frontal sinus more 
frequently than any other fatal complication. 

The Ogston-Luc method would seem to bear the brunt of most 
of these cases , 496 the exciting factor being the incomplete removal 
of all the suppurating ethmoid cells . 497 Injury to the lamina crib- 
rosa also plays an important role. 

After the Killian operation a number of deaths from menin¬ 
gitis have been reported, although the path of infection has not 
always been made clear . 498 - 503 Tearing out the olfactory fila¬ 
ments in exenterating the ethmoid cells is undoubtedly a prolific 
source of this postoperative complication, as the autopsy on many 
of these cases proved that no injury had been inflicted on the lamina 
cribrosa, yet the path of infection had occurred through that 
structure. The osteoplastic resection has also been followed by 
unpleasant sequelae, and in one case by death from meningitis . 504 

THE ULTIMATE AND PERMANENT CONDITION OF THE OPERATED FRONTAL 


SINUS. 


It has unquestionably been the hope of operators that after the 
primary healing had occurred the sinus would ultimately be covered 
by normally regenerated mucosa. This, however, is rarely the 
case, and never takes place in those sinuses in which any consider¬ 
able areas of mucous membrane have been denuded, for, in regener- 
ating, the ciliated columnar epithelium is replaced by the squamous 
or pavement type, thus losing the action of the cilia in distributing 
secretion and expelling extraneous substances. Despite this, it 
has been shown that it is possible to cause nature to entirely 
obliterate the sinus cavity with newly-formed spongy tissue. 


496. Coffin: Intracranial Complications of Diseases of the Accessory Sinuses. Med. 
Record, yol. 72, p. 767, 1907. 497. Luc (Soc. Franc, d’otol., T. 20, p. 18, 1904) himself 
j 8 ^PFl 1011 * a , | ias abandoned the operation bearing his name for the procedure 
ol Killian. 498. Mermod: Lepto- meningite apres une operation de Killian. Arch, inter, de 
u?" • ' 2 ?’ P-5b 1905. 499. Oppikofer: Sinusite Frontale purulente chron. avec abces 
orbitaire. Arch, inter, de Lary., T 24, p. 811,1907. 500. Von Eicken (457), S. 238. In one 
ol these cases the infection occurred through a tampon saturated with pus from a suppurating 
maxillary sinus. The path lay through the lymph-channels around the olfactory fibres 
through the cribrifomi plate to the olfactory bulb and thence to the pia mater. 501. Rein- 
king; Dis. zu Hajek s Vortrag Vehr. d. deutsch. Larv. Gesell., S. 131, 1907. 502. Hajek: 
Wem Lary. Gesell. Mon f. Ohrenhk., S. 118, 1909. 503. Boenninghaus (479), S. 190, has 
collected the number of deaths m relation to the number of operations following the Killian 
method: 375 operations, with seventeen, or 2.6 per cent., deaths. Hajek 503 *adds nine cases 
to this, three having been published and six remain unpublished. I must unfortunately add 
another to this latter class. 




FRONTAL SINUS 


303 


Name of author 

7. Jacques 504e. 

8. Jacques 504c. 

9. Killian-Eicken 504f. 

10. Killian-Eicken 6041 . 

11. Killian-Eicken 504f. 

12. Koschier 504g. 

13. Lindt 504h. 

14. Mermod 504i. 

15. Noltenius 504 k. 

16. Oppikofer 5044 . 

17. Ritter 504m. 

18. Report of Seraphin Hos¬ 

pital 504n. 

19. Siebenmann 504o. 

20. Van den Wildenberg 504p. . . . 

21. R. H. Skillern. 

21a. R. H. Skillern.. 


22. Freudenthal 504r 

23. Herzfeld *. 

24. Mackenty 504 * . 

25. Coffin 504s. 

26. Imperatori 504t . 


27. Phillips 504s... 

28. Smith, H. 504s . 

29. Smith, H. 504s. 

30. Richardson 504s 

31. Goldsmith 504w 

32. Brown 504x 

33. Scruton 504s . . . 

34. Leopold 504y .. , 

35. Shurley 504z .. . 

36. Butler 504za 


Cerebral complications. 


Details 


Meningitis 48 hours after 
operation 

Meningitis 48 hours after 
operation 

Meningitis. 


Progressive osteomyelitis 
after primary suture 


Metastatic abscess in the 
lungs 

Meningitis eight days 
after operation 

Meningitis two days after 
operation 

Meningitis four days 

after operation 

Meningitis two days after 
operation 

Postoperative meningitis 


Infection through the lymph-sheaths of the 
olfactory nerves. 

Infection through the lymph-sheaths of the 
olfactory nerves. 

Infection through the lymph-sheaths of olfao- 
tory nerves. Simultaneous purulent maxil¬ 
lary sinusitis. 


From splenoid sinus which has not been 
opened 


Large defect in lamina cribrosa. 


Progressive osteomyelitis 
after primary suture 
Death from progressive 
osteomyelitis 
Meningitis immediately 
following operation. 
Death on fourth day. 
Meningitis. First mani¬ 
festation 48 hours after 
operation. Death on 
3rd day 

Meningitis. Thrombus 
in lung. Sinus 

Epidural abscess. 

Meningitis—third day 
Meningitis 

Second operation five 
years after first. Splen¬ 
oid curetted. 

Meningitis and brain 
abscess 

Meningitis. 

Septicaemia two weeks 
Meningitis five days.... 
Osteomyelitis and brain 
abscess 

Meningitis. Death two 
months after operation 
Meningitis. Death on 
fourth day. 

Purulent leptomeningitis 
Death on fourth day 

Meningitis 

Meningitis. Third day. 
Death same night 


Through maxillary sinus which had not been 
opened. 

After primary suture and from subsequently 
operated maxillary sinus. 

Probably through sheath of olfactory nerves. 
No autopsy. 

Autopsy. Intense congestion of brain. Ven¬ 
tricles filled with turbid fluid. No pus. 
Original focus of infection not discovered 
504 q. 

No autopsy. 

Purulent meningitis. 

No autopsy. 

Basal meningitis. Bone intact. Influenza 
bacillus. 


N o autopsy 

Beginning meningitis at time of operation. 
Frontal lobe abscess entire brain injected. 


Subdural abscess in frontal lobe. 


Autopsy. Dura bulging. Purulent exudate 
over right frontal lobe. Longitudinal sinus 
filled with pus. 

No details. 

Chronic suppurative meningitis. Pneumo- 
coccic 


503a. Hajek: Lehrbuch, 1915. S. 252, note. 504. Hoffman: Ueber Osteoplastische 
Operationen der Stirnhohle. Verh. d. deutsch. Lary. Gesell., S. 132, 1907. 504a. Grant: 
Cent. f. Larynx, S. 157,1910. 504b. Hajek: Die Behandlung der Empyeme der Nasennen- 
















































304 


THE ACCESSORY SINUSES OF THE NOSE. 


Ssamoylenko * operated on the frontal sinuses of dogs and cats, using the 
following technic: One sinus was opened by resecting most of the anterior Avail; 
the lining mucosa was thoroughly removed by curettage and the cavity dried with hot 
air. Tincture of iodine was painted over the denuded surfaces, and the Avound 
closed under antiseptic precautions. The sinus on the opposite side was left un¬ 
touched for purposes of control. After various lengths of time the animals were 
killed and sinuses opened, Avith results as follows: After two weeks the sinus begins 
to close from the loAvest angle Avith a marroAV-like substance, which eventually fills 
the cavity, ossification commences about the third month. In this manner complete 
obliteration of the sinus with neAv-formed bone tissue occurs. As the bony structure 
of these animals is identical with that of man, it is certain that under similar condi¬ 
tions these changes also occur in the human being. 


Name of Author 

Cerebral Complications 

1 Grant 8043 

Meningitis. 

2. Grant 504a 

Meningitis. 

3. Hajek 60415 . 

Death from meningitis 
three days after op¬ 
eration 

Subdural and intra¬ 
dural abscess six 
days after operation 

Osteomyelitis. Puru¬ 
lent lepto-menin- 
gitis 

Meningitis three days 

4. Hajek 504b . 

5. Heine 8040 . 

6. Hosch 504d . 


after operation 


Details 

Apparent infection through the veins. 
Apparent infection through lymph- 
vessel. 

No autopsy. 


Fracture of the crista galli and lacera¬ 
tion of dura. 


benhohlen. Zeit. f. Laryng,. Bd. 2, S. 481, 1910. 504c. Heine: Berl. Otol. Gesell. Monat. 

f. Ohrenhk., S. 568, 1906. 504d. Hosch: Unsere Erfolge der Radikal Operation des Sinus¬ 

itis frontalis. Zeit. f. Ohrenhk., S. 347,1910. 504e. Jacques: Congres Francaisd’Oto. Rhino. 
Laryngologie. Ann. d. Mai. de Torielle du Laryngology, T. 36, p. 610,1910. 504f. Killian- 
Eicken: Unsere Erfarungen mit der Killianschen Stirhohlen operation. Verh.d. 1 Intemat. 
Laryng. Kongr. Wien, S. 328,1909. 504g. Koschier: Wein. Laryng. Gesell. Monat. f. Ohrenhk., 
S. 428,1910. 504h. Lindt: Cited by Luc. Complic. Craniennesetintracraniennesdes Antrites 
Frontales suppurees. Ann. d. Mai. de Toreille du Laryngology, T. 35, p. 325,1909. 504i: Mer- 
mod: Lepto-Meningite apres une operation de Killian. Archiv. int. de Laryng., T. 20, p. 48, 
1905. 504k. Noltenius: Cited by Thiele. Archiv. f. Laryng., Bd. 14, S. 543,1903. 5041. Oppi- 
kofer: Sinusite Frontale purulente chron. et Archiv. int. de Laryng., T. 24, p. 811, 1907. 
504m. Ritter: Berl. Otol. Gesell. Monat. f. Ohrenhk., S. 569,1906. 504n. Report of Seraphin 
Hospital, Stockholm. 504o. Siebenmann: Zeit. f. Ohrenhk., S. 362, 1910. 504p. Van 

den Wildenberg: Tod. nach. progressiver Osteomyelitis, etc. Yahres-Versam. d. Belgisch. 
oto-rhino-laryng. Gesell. Cent. f. Laryng., S. 467, 1909. 504q. Skillern: Death Following 

Double Killian Operation on Frontal Sinuses. Penna. Med. Journ., p. 302, Sept., 1920. 
504r. Freudenthal: Brain Infection in Sinus Disease. Trans. Am. Ac. Ophthal. and Oto- 
Laryng., 1913. 504s. Personal Communication. 504t. Imperator: Report of a Case of 

Chronic Frontal Sinusitis, etc. Laryngoscope, p. 580, 1915. 504w. Personal Communication 
by D. J. G. Wishart. 504x. Personal communication by Hill Hastings. *Cited by Freud¬ 
enthal (504r). 504y. Leopold: Journ. A.M.A., May 27, 1916. 504z. Shurley: Personal 

Communication. 504za. Butler: Meningitis Due to Frontal Sinus Suppuration with a Re¬ 
port of Three Fatal Cases. Ann. Otol., Rhin. and Laryng., p. 666, Sept., 1920. 

*Ssaymoylenko, Postoperative Verordung der Stirnhohlen. Arch, f. Laryng., Bd. 27, 
p. 137, 1913. 




















PART IV. 

ETHMOID LABYRINTH. 

ANATOMY. 

The ethmoid labyrinth embraces all that portion lying between 
the two lateral plates of the orbit. (Fig. 14.) It is composed of 
two capsules, with a partition (lamina perpendicularis) between. 
The capsules have a prolongation at their internal inferior angle 
which corresponds to the middle turbinate. The external infe¬ 
rior angle or body of the capsule represents the ethmoidal bulla, 
and is the most dependent portion of the cellular structures. Im¬ 
mediately beneath the bulla may be observed the cross section of 
the uncinate process, which at its curve is the lowest portion of 
the ethmoid bone.* It will be noted that the ethmoid occupies 
approximately one-half of the entire space between the floor of 
the nose and the cribriform plate. The lamina cribrosa and 
lamina papyracea do not meet, but allow a vacant space, which 
is covered in by the fovea ethmoidalis of the frontal bone. (See 
page 13.) Along the internal lateral wall of the capsule a pro¬ 
jection occurs which represents the superior turbinate. It will 
be at once apparent that this is not a true turbinate bone, but 
rather formed by an indentation in the body of the ethmoid. If 
the section is made through the anterior ethmoidal cells this 
structure will not be visible. The ostia of the anterior ethmoidal 
cells lie beneath the middle turbinate in the middle passage, while 
those of the posterior labyrinth empty into the superior nasal 
passage below the superior turbinate. 

LATERAL NASAL ASPECT. 

The relation of the ethmoid capsule to the lateral wall of the 
nose will be observed in Fig. 9. The anterior boundary is appar¬ 
ently formed by the anterior border of the middle turbinate, 
although the actual boundary is represented by the uncinate 
process. The posterior border corresponds to the anterior 
sphenoidal wall, or, when present, to the spheno-ethmoidal fissure. 
The pendulous portion of the middle turbinate enters so slightly 
into the formation of the capsule proper that it should be removed 

* The pendulous middle turbinate not being considered. 

20 


305 



306 


THE ACCESSORY SINUSES OF THE NOSE. 


in order to minutely study the lateral wall. (Fig. 10.) It will 
be observed that the capsule is composed of several furrows run¬ 
ning in an oblique direction from behind forward and below 
upward. As these represent the fundamental ground-work of the 
entire structure if would be well to apply the scheme of Seydel 005 
for our further consideration of this labyrinth. 

For the purpose of understanding the construction of this 
capsule let us suppose that a box was fitted up with four curved 



Fig. 172.—Schematic reproduction of the construction of the ethmoid capsule. L. 1. Partition of 
uncinate process. L. 2. Partition of the ethmoidal bulla. L. 3. Partition of the middle turbinate. L. 4. 
Partition of the superior turbinate. L. 5. Partition of the supreme turbinate. 

partitions, three complete and one partial. (Fig. 172.) The three 
posterior partitions extend completely from the top to the bottom, 
making these closed spaces, while the anterior incomplete one 
reaches from the bottom but halfway to the top. The box is 
now covered by a lid which extends some distance below the lower 
edge. The ethmoid capsule may be compared with this structure. 
The lid which corresponds to the middle and superior turbinate 
is raised, bringing into view the partitions which correspond to 
the lamella? of the various structures which enter into the forma- 


505. Seydel: Ueber die Nasenhohle der hoheren Saugethiere u. d. Menschen. Mor- 
pholog. Jahrebiicher. Leipsig, 1891. 











ETHMOID LABYRINTH. 


307 


tion of the labyrinth. (Fig. 172.) Partition or lamella No. 1 rep¬ 
resents the uncinate process, lamella No. 2 the bulla ethmoidalis, 
lamella No. 3 the middle turbinate, and lamella No. 4 the superior 
turbinal passages. Above these grooves lie the network of cross 
lamellae which form and constitute the ethmoid cells. The number 
and size of these cells depend upon the position of the lamellae. 

LAMELLA OE UNCINATE PROCESS. 

Unlike the remaining, this structure does not reach the frontal 
bone (fovea ethmoidalis), but takes its origin from its fellow 
(lamella of bulla). By curving downward below and at equal 



distance from the bulla it forms the passage known as the semi¬ 
lunar hiatus. Its partial failure above allows the frontal sinus 
to empty into the hiatus semilunaris, otherwise this sinus would 
be occluded. At that point where this lamella joins with that of 
the bulla a pocket is formed, causing the hiatus to end blind. This 
to a greater or lesser degree may be found on nearly every speci¬ 
men. Occasionally an ethmoid cell buries itself under the lamella 
of the uncinate process, a condition which adds to the difficulty 
of sounding the frontal sinus. This cell is situated for the most 
part directly under the prominence of the agger nasi causing a 
marked enlargement of the hiatus semilunaris at this point or 
directly at the junction with the frontal sinus. The surgical im¬ 
portance of this will at once be apparent, for should the wall on the 
nasal aspect be opened, it immediately constitutes a short cut to 
the frontal sinus from the nose. 




308 


THE ACCESSORY SINUSES OF THE NOSE. 


LAMELLA OF THE BULLA. 

This represents the first complete partition of the ethmoid 
capsule and reaches from the pars orbitalis of the frontal bone to 
the capsular base as well as from the lateral nasal surface to the 
lamina papyracea. When the inferior portion of this lamella is 
opened, the lowest part of the ethmoid capsule is penetrated. The 
shape of this structure varies greatly in the normal individual, 
sometimes it is quite flat and inconspicuous (Fig. 173), sometimes 
considerably enlarged and very prominent (Fig. 174). The largest 
and most constant ostium of the anterior ethmoid cells lies in the 
passage between this structure and the middle turbinate about in 
the centre of the bulla. (Fig. 174.) 


Nasofrontal duct 


Hiatus semilunaris 


Fig. 175.—Formation of ductus nasofrontalis. 

The presence or absence of a nasofrontal duct is due to the 
position of this lamella. If the lamella of the bulla is situated far 
forward at its superior extremity it encroaches upon the floor of 
the frontal sinus, causing the latter to become fore-shortened. 
Under these circumstances a narrow passage is formed before the 
ostium of the sinus is reached. (Fig. 175.) The length and breadth 
of this duct depend entirely upon the position of the bulla lamella. 
It is formed by the following structures: In front by the superior 
nasal spine, externally by the lamina papyracea, behind by the 
bulla lamella and internally by the external surface of the 
middle turbinate. 

LAMELLA OF MIDDLE TURBINATE. 

This also represents a complete partition, being the longest of 
all the lamella, and is of particular importance because it repre¬ 
sents the dividing line between the anterior and posterior eth- 









ETHMOID LABYRINTH. 


309 


moidal labyrinth. If this lamella lies in front of its normal posi¬ 
tion, the posterior labyrinth is correspondingly enlarged, and 
vice veisa. All of the ostiums of the posterior cells empty above 
and behind this structure. 

It is not possible to judge from mere position whether a certain cell belongs 
to the anterior or posterior labyrinth, as it is possible for one lying directly over 
the bulla to empty into the superior nasal passage. As the lamella of the middle 
turbinate separates the middle from the superior nasal passage, this structure is 
necessarily the partition which separates the anterior and posterior labyrinths; 
therefore, it would be more correct, from an anatomical point of view, to designate 
the cells according to their drainage, i.e., cells of middle nasal passage and cells 
of superior nasal passage. 


LAMELLA OF SUPERIOR TURBINATE. 

While this partition is short, nevertheless it is complete, reach¬ 
ing to the posterior base of capsule. It assists in forming the 



Fig. 176.—Cross section through the ethmoid close to the cribriform plate. 


superior nasal passage, and contains the ostiums of the posterior 
ethmoid cells. This plate of bone holds an intimate relation with 
the anterior wall of the sphenoid and enters largely into 
the formation of the spheno-ethmoidal fissure. If it inserts near 
the median line, this fissure is not well marked, while if it curve 
backward and outward, a considerable recess between the pos¬ 
terior body of the capsule and the anterior wall of the sphenoid 
results. (Fig. 176.) 

The number of cells in each labyrinth varies in the normal 
subject, the lowest number being two or three (Fig. 177), the 
highest about ten or twelve (Fig. 178). They appear to bear no 
especial relation to one another, and their form and size vary to 







310 


THE ACCESSORY SINUSES OF THE NOSE. 


such an extent that two ethmoidal labyrinths rarely present the 
same formation, although from the orbital aspect it is usually 
possible to trace out the different lamellae. (Figs. 179, 180.) On 
this account the ostiums must vary in number. Each cell has its 



separate outlet, although some may empty into others before 
finally apearing in the nasal cavity. The total capacity of the 
entire labyrinth approximates 8 to 10 cubic centimetres. 506 The 



anterior cells empty into the hiatus semilunaris and into the middle 
nasal passage, and are not confined to any given number. 

Anterior cells consist of those of the infundibulum (infundibular cells), those 
of the pre-ethmoidal recess, and those of the bulla. 

Infundibular cells can occur in three places: Anterior, superior and posterior 


506. Sieur and Jacob: Les Fosses Nasales et leurs Sinus, p. 231, Paris, 1901. 












ETHMOID LABYRINTH. 


311 


(Fig. 181). The usual positions are anterior under the uncinate process, and 
superior under the attachment of the ground lamella of the bulla to that of the 
uncinate process. 

The anterior cell, when present, lies beneath the agger nasi, and, as its ostium 
in the hiatus semilunaris is situated directly below the ostium of the frontal sinus 
(Fig. 181), it has been suggested that the sinus may be reached by the probe by this 
route with greater facility than by the old method of first going beneath the middle 



turbinate. 5064 In attempting this procedure it is, of course, necessary to resect the 
nasal wall of the agger nasi. 

Pre-ethmoidal recess. Cells which empty into this space are those lying be¬ 
tween the lamella of the middle turbinate, lamella of the bulla and orbital plate 
of frontal (Fig. 182). The fronto-ethmoidal cells may be included in this category. 

These cells by impinging upon the naso-frontal duct cause it to assume a 
tortuous course, thereby interfering with drainage in the event of infection of the 
frontal sinus (Fig. 183). 

Bulla cells. The ostiums of the cells entering into the formation of the bulla 
are situated in the recess formed by the bulla and middle turbinate and sometimes 
in front, emptying directly into the hiatus semilunaris. 



The posterior cells are somewhat more regularly placed, one 
being forward at the junction of the middle and superior turbinate, 
one lying laterally and one posterior and superior. 


506a. Mosher: The Applied' Anatomy and the Intranasal Surgery of the Ethmoidal 
Labyrinth. Trans. Am. Laryng. Assn., p. 25, 1912. 









312 


THE ACCESSORY SINUSES OF THE NOSE. 


The anterior of these lies immediately behind the bulla, so that the posterior 
wall of the bulla represents the anterior wall of the posterior ethmoidal cell. This 
cell may occupy a large portion of the inner wall of the orbit or may be prolonged 
into the orbital vault or even the frontal bone. 

Lateral cell. Sometimes this cell pushes itself into the lesser wing of the 
sphenoid, under which circumstances it lies beneath the optic nerve and ophthalmic 
artery. 

Posterior cell. This cell forms the posterior boundary 
of ethmoid labyrinth and at the same time the anterior wall 
of the sphenoid. 

Strictly speaking, cells of the anterior and 
posterior labyrinth are misnomers, as fre¬ 
quently a cell will be found situated in the 
anterior portion of the capsule which empties 
into the superior nasal passage. Under these 
circumstances it would be better to divide the 
labyrinth into cells of the middle nasal passage 
and cells of the superior nasal passage. The 
gross relation of the ethmoidal labyrinth to the 
true sinuses may be seen in the schematic draw¬ 
ing taken from Hajek. (Fig. 21.) 

A horizontal section of the entire ethmoid labyrinth shows 
that it is broader behind at its junction with the sphenoid than 
in front where it is in relation to the frontal sinus. (Fig. 176.) 
The posterior measurement between the nasal wall and lamina 



Fig. 181.—Diagrammatic 
representation of infundibu¬ 
lar cells. F. S., frontal sinus. 
E. C., ethmoid cell. H. S., 
hiatus semilunaris. 



papyracea is about 1.5 cm., while anteriorly in the region of the 
lachrymal bone it may only measure 0.5 to 0.8 cm. This is of 
great importance to remember while using a hook or Ballenger 







ETHMOID LABYRINTH. 


313 


knife, as a mueli deeper incision can be made posteriorly without 
fear of injuring the os-planum, but if the instrument is drawn 
straight forward the lachrymal bone is sure to be encountered. 

RELATION OF ANTERIOR ETHMOID LABYRINTH TO FRONTAL SINUS /' 07 

One can hardly speak of a strict normal relation between these 
two structures, as deviations and irregularities are found in almost 
every skull examined, yet for purposes of comparison a certain, 
standard must be accepted. If the lamella of the uncinate process 
and bulla are normal in every respect (size, shape and position), 
the frontal sinus coming down in the shape of a funnel, we can 



Fig. 183.—Frontal sinus and hiatus semilunaris forming a straight passage. 

consider this the normal type. Under these circumstances the 
semilunar hiatus and the frontal sinus would form a continuous 
and straight passage, the bulla lying posterior and somewhat 
superior. (Fig. 183.) 

ANOMALIES OF ETHMOID LABYRINTH. 

Deviations from the normal may occur in several ways: 

1. By malposition or displacement of the lamellae. 

2. By partial or complete absence of lamella. 

3. By projections of the air spaces beyond the borders of the 
ethmoid capsule into other structures. 

507. Heyman and Ritter: Zur Morphologie und Terminologie des mittleren Nasen- 
ganges. Zeitschr. f. Laryngologie, Bd. 1, S. 1, 1909. 




314 


THE ACCESSORY SINUSES OF THE NOSE. 


4. By dehiscences. 

1-2. As these anomalies are dependent upon irregularities in 
the lamella, they will be considered under one head. 

(a) In the lamella of uncinate process: The principal anoma- 


Posterior ethmoid 
cells 


Sphenoid sinus 


Superior nasal 
passage 



Frontal bulla 


Cell in agger nasi 


Uncinate process 


Bulla 


Fig. 184.—Frontal bulla formed by the upward and forward displacement of the lamella of bulla ethmoi- 

dalis onto the posterior wall of the frontal sinus. 

lous formations of the structure occur in the following ways: (1) 
upward extension of lamella; (2) partial failure of lamella; (3) 
tell dividing lamella. 


Entrance into frontal 
sinus 


Lamella of bulla 


Uncinate process 



Superior nasal passage 


Fig. 185. Anomalous situation of the uncinate process. Frontal sinus emptying into an 

anterior ethmoid cell. 


(1) Upward extension of lamella (Fig. 184). This plate, in¬ 
stead of taking its origin from the bulla, rises upward into the 
frontal sinus, forming a cell at the base of this cavity. This is 
one of the forms of the so-called frontal bulla. 508 It would be 

508. Shambaugh: Construction of Ethmoidal Labyrinth. Ann. Otol., Rhin. and Larv., 
Dec., p. 771, 1907. 






















ETHMOID LABYRINTH. 


315 


difficult to sound the frontal sinus in the presence of this anomaly, 
as the point of the instrument would find lodgment in the frontal 
bulla unless the sound closely followed the mesial side of the 
middle turbinate. 



(2) Partial failure of lamella (Fig. 185). The uncinate proc¬ 
ess takes its origin from the base of the ethmoidal bulla, thereby 
obliterating the anterior portion of the hiatus semilunaris. The 



frontal sinus opens into an anterior ethmoid cell (bulla), which 
in turn communicates with the middle nasal passage through its 
normal ostium. This formation absolutely precludes the possi¬ 
bility of introducing a sound into the frontal sinus. 









316 


THE ACCESSORY SINUSES OF THE NOSE. 


(3) Cell dividing lamella of uncinate process (Fig. 186). When 
an air space is formed in this, process it is always situated 
at the base or at that portion of the lateral nasal wall which 
is known as the agger nasi. The ostia of these cells always empty 



Fig. 188.—Downward displacement of bulla with obliteration of the hiatus semilunaris. 

into the infundibulum and are known as infundibular cells. (Fig. 
186.) An infundibular cell at the anterior extremity of the hiatus 
may bulge into the frontal sinus, forming another variety of a 
bulla frontalis. (Fig. 187.) 

(b) In the lamella of the bulla ethmoidalis: The bulla is prac- 


Superior nasal passage 



Hiatus semilunaris 
Bulla 


Fig. 189.—Upward displacement of bulla with enlargement of the hiatus semilunaris. 


tically always constant, but is subject to various deviations from 
the normal. These irregularities are seldom due to an absence 
of portions of the ground lamella, hut rather to some malposition 
or displacement. These displacements may be (1) downward, 
(2) upward, (3) forward, and (4) backward. 










ETHMOID LABYRINTH. 


317 


(1) Downward displacement of ethmoidal bulla (Fig. 188). 
Comparing this with the normal, it will be seen that the bulla 
is situated further downward and backward, causing a consid¬ 
erable space to be formed between the connecting lamella of the 



Fia. 190.—Formation of a frontal bulla through the upward extension of the lamella of the uncinate process. 


uncinate process and bulla and the frontal ostium. Under these 
circumstances the hiatus has absolutely no relation with the fron¬ 
tal sinus. In order to sound this cavity the instrument must be 
introduced far above the bulla. 

(2) Upward displacement of the bulla (Fig. 189). This 



formation is, in reality, due to lack of development in the bulla. 
The ground lamella does not project into the middle nasal 
passage in any marked degree, but leaves a large free passage 
into the frontal sinus. This is one of the most favorable forma¬ 
tions for introducing a catheter into the frontal sinus. 










318 


THE ACCESSORY SINUSES OF THE NOSE. 


(3) Forward displacement of bulla (Fig. 185). The bulla 
lamella is pushed forward against the uncinate process, thereby 
obliterating the hiatus. In our specimen the only apparent outlet 
to the frontal sinus is situated close to the cerebral wall. In 



order that the frontal sinus may have an outlet, an opening is 
formed in the lamella of the bulla. When the lamella runs up 
into the frontal sinus another variety of frontal bulla is formed 
(Fig. 190.) 


Pre-ethmoidal 


Infundibular cell 


Hiatus semilunaris 



Posterior ethmoid 
cells 


Superior nasal 
passage 


Fig. 1®3. Showing reduced size of ethmoid labyrinth in the absence of the frontal and sphenoidal s 
vV ell-marked infundibular cells. 


(4) Backward displacement of bulla (Fig. 191). When 
this structure is displaced backwards a vacant space occurs above 
the end of the hiatus and in front of the lamella of the bulla. As 
this space lies in front of the ethmoid capsule proper, yet com- 








ETHMOID LABYRINTH. 


319 


municates with the nose inside of the semilunar hiatus, it might 
be well to designate it as the pre-ethmoidal recess. When this 
anomaly is present the frontal sinus finds its outlet at this point. 

( c ) In the lamella of the middle turbinate: The only change of 
note observed in this lamella is that of malposition forward or 
backward. In the first instance, if the ground lamella lies too far 
forward, it naturally, being the boundary between (Fig. 192) the 
anterior and posterior labyrinth, reduces the size of the space 
occupied by the anterior cells and enlarges that for the posterior. 



Fig. 194 .— Fronto-ethmoidal cell extending almost the width of the orbit. Cell in crista galli. 


If it lie too far backward, the opposite is the case; therefore, the 
relation of the anterior to posterior group of cells depends en¬ 
tirely upon the position of the ground lamella of the middle 
turbinate. 

(d) In the lamella of the superior turbinate: When the lamella 
of the superior turbinate assumes a horizontal direction the pos¬ 
terior ethmoidal cell will occasionally override the sphenoid 
sinus, giving the appearance on section as though the sphenoid 
sinus was divided by a partition. (Fig. 192.) 

(e) Extension of entire labyrinth (Fig. 178): The anterior 






320 


THE ACCESSORY SINUSES OF THE NOSE. 


cells extend over the hiatus almost into the nasal bones, while the 
posterior occupy some of the space normally held by the sphenoid 
sinus. The number of cells in both labyrinths is fourteen—six 
in the anterior and eight in the posterior. 

(/) Contraction of the entire labyrinth (Fig. 193) : The cells 
are pushed together antero-posteriorly, occupying much less space 
than normally. The entire labyrinth is composed of but six cells, 
all of them having the appearance as though compressed from 
behind, forward. Neither sphenoid nor frontal sinus is present. 



Fig. 195.—Fronto- or orbito-ethmoid cell. Frontal sinus lies directly in front and does not communicate. 


3. By Projections of the Air Spaces. —Normally, the cells of 
the ethmoid labyrinth are contained within the limits of the eth¬ 
moidal capsule. Under certain circumstances they may extend 
far beyond these boundaries into the (a) frontal, (b) maxillary, 
and ( c ) sphenoid bone, and occasionally into the ( d) middle 
turbinate. 

(a) Fronto-ethmoidal cells: These are formed by burrowing 
their way between the orbital plate of the frontal bone, and may, 
in extreme cases, extend almost the entire width of the orbit. 





ETHMOID LABYRINTH. 


321 


(Fig. 194.) They frequently present themselves in the supra¬ 
orbital ridge outside v of the frontal sinus, from which they are 
always separated by a thin partition. (Fig. 195). The ostiums 
of these cells are usually situated in the superior portion of the 
middle nasal passage, directly posterior to that of the frontal 
sinus, so that in case of their presence, in sounding it would be 
impossible to judge into which the instrument had penetrated. 

(b) Maxillo-orbital cells: These are caused by the bulla 
occupying a lower position than normal, whereby the outer wall 
of the lowest cells is formed by the orbital wall of the superior 
maxillary instead of the lamina papyracea of the ethmoid. (Fig. 
40.) No especial significance need be attached to these, as they 
are readily reached through the nose when necessary. 

( d ) Cell in middle turbi¬ 
nate: This anomalous for¬ 
mation consists of one or 
more cells which have hol¬ 
lowed out the body of the 
middle turbinate. (Fig. 196.) 

It was formerly supposed that 
these cells were bone cysts and of 
pathologic origin^ Investiga¬ 
tion, 509 510 511 however, has shown 
that this theory was false, for the 
following reasons: 

1. They contain ostia as any 
other ethmoidal cell. 

2. The whole structure from a 
microscopical point of view is 

Fig. 196.—Anomalously situated ethmoid cell occupying • -i f oorrp^nondino- healthv 
the anterior extremity of the middle turbinate. Similar 10 a corresponding neaiiny 

portion of the ethmoid capsule. 

3. No evidence is presented that any pathological process has contributed to 
the formation of the structure. 

These cells may be of any size, from a mere indentation in the 
base of the middle turbinate to an enormous distention of the 
entire structure, completely occluding the naris on that side. They 
undoubtedly grow during adult life under normal circum¬ 
stances. 505 The ostia of these cells are usually situated in the 
superior nasal passage at the angle of junction of the middle and 
superior turbinates, but occasionally empty into the middle nasal 

509. Kikuchi: Der histologische Bau der Knochenblasen in der Nase, etc. Arch. f. 
Laryn., Bd. 14, S. 308, 1903. 510. Lothrop: The Anatomy of the Inferior Ethmoidal 

Turbinate Bone, etc. Annals of Surgery, vol. 38, p. 233, 1903. 511. R. H. Skillem: Bei- 

trag zur Kenntnis der Sogenannten Knochenblasen der mittleren Muschel. Arch. f. Lary., 
S. 254, Bd. 23, 1910. 

21 








322 


THE ACCESSORY SINUSES OF THE NOSE. 


passage, the ostia there being situated on the external aspect of 
the middle turbinate opposite the ethmoidal bulla. 

4. Dehiscences , 512 —Congenital defects have been noted in cer¬ 
tain portions of the ethmoid capsule, particularly the lamina 
papyracea. In the recent state the break in the continuity of the 
bony structure is covered in by fibrous tissue. The significance 
which these anomalies bear is in direct relation to the facility with 
which infection may travel from the diseased ethmoid cells to the 
orbital structures. Emphysema of the orbit has been observed 
on forcibly blowing the nose or sneezing, a circumstance which 
must be attributed to the pressure of dehiscences in the bony 
partition between the nose and the orbit (lamina papyracea). De¬ 
fects have also been noted in the superior w 7 all of the posterior 
cells. 513 

The mucosa lining the cells of the ethmoid labyrinth is similar 
to that of the sinuses, except somewhat thinner. It contains some 
few glands—sufficient to keep the surface moist. The olfactory 
filaments are situated on the superior turbinate, about in its 
centre. 

BLOOD SUPPLY. 

The ethmoid obtains its blood supply from the superior nasal 
branch of the sphenopalatine, as well as the anterior and posterior 
ethmoidalis, which spring from the ophthalmic artery. (Plate 
la.) None of these arteries is of any considerable size. 

VENOUS ANASTOMOSES. 

Veins are divided into two groups: 1. Ethmoidal veins re¬ 
turning along the course of their respective arteries, penetrating 
the anterior and posterior ethmoidal foramina into the orbit, 
finally emptying into the ophthalmic vein which empties into the 
cavernous sinus. (Plate I b.) 

2. The ethmoidal veins on the cribriform plate anastomose 
freely with the veins of the dura mater and the superior longitu¬ 
dinal sinus. These explain why thrombosis of the longitudinal 
and cavernous sinus can occur from purulent ethmoiditis. They 
also explain why cases of meningitis following ethmoiditis have 
occurred without the intervening bone being affected. 


512. Onodi: Die Dehiscenzen der Nebenhohlen der Nase. Arch. f. Lary., Bd. 15, S. 
62, 1903. 513. Sieur and Jacob (506), p. 253. 



ETHMOID LABYRINTH. 


323 


RELATION OF POSTERIOR ETHMOIDAL CELLS TO OPTIC NERVE . 514 

The normal relation of this nerve to the posterior ethmoidal 
cell of moderate size is only at the posterior, superior and exter¬ 
nal angle, and is separated by several millimetres. (Fig. 197.) 
As the optic nerve leaves the chiasm it courses through the optic 
groove toward the centre of the eyeball, taking, of necessity, an 
outward and forward course. The normal ethmoid labyrinth 
being directed solely forward, it stands to reason that these two 
structures diverge as they run anteriorly. In certain anomalous 



turbinate 

turbinate 

turbinate 


Inferior turbinate 


Posterior ethmoid 
cell 


Sphenoid sinus 


Optic 


Fig. 197. Lateral wall of nose with spheno-ethmoidal cell showing intimate relation of optic nerve 

Onodi.) 


(After 


formations the posterior ethmoid cells may extend into the lesser 
wings of the sphenoid. Under these circumstances the optic nerve 
lies for several millimetres of its course almost within the cavi¬ 
ties of these cells, being separated from them by a thin layer of 
mucosa, or, at best, by an incomplete bony canal. (Fig. 198.) It 
depends entirely upon the amount of reabsorption that has 
occurred as to the proximity of the nerve. The importance of 
being cognizant of this anomalous possibility is obvious, particu¬ 
larly when considering blindness of nasal origin. 315 


514. Onodi: Das Verhaltmss des Nervns opticus zu der Keilbeinhohle u. d. hinteresten 
Siebbeinzellen. Arch. f. Lary., S. 360, Bd. 14, 1903. 515. Loeb: The Optic Nerve and the 
Accessory Cavities of the Nose. Ann. Otol., Rhin. and Lary., p. 243 1909 









324 


THE ACCESSORY SINUSES OF THE NOSE. 


PHYSIOLOGY OF THE ETHMOID. 

A different function must be attributed to the ethmoid cells 
from the sinuses proper, however great our ignorance of the 
physiological significance of the latter may be. In the first place 
the anatomical configuration of the two structures is totally dis¬ 
similar. The sinuses (frontal, maxillary and sphenoid) are true 
cavities enclosed by bony walls and outside of, or adjunct to, 
the nasal cavity proper. The ethmoid labyrinth, on the other 
hand, may be likened unto a sponge and is contained within the 
boundaries of the respiratory portion of the nose. 



Periorbital 


Sphenoid sinus 

Lesser wing of sphenoid 

Optic nerve 


Frontal sinus 
Frontal sinus 


Middle 
cerebral fossa 


Optic chiasm 


ca¬ 
rotid artery 


Maxillary sinus 

Septum 


Optic nerve 
Sphenoid sinus 


Septum 


Orbit 


Fig. 198. —Normal relation of optic nerves to sphenoid sinus and posterior ethmoid cells, xx Ethmoid 
cells. S. Sphenoid sinus. (After Onodi.) 


From these anatomical facts and from the experiments of 
Paulsen, 516 Zwaardemacher, 517 and others on the air currents 
passing through the nose during inspiration and expiration (Fig. 
199), we can state definitely that this structure exercises great 
influence on the warming and moistening of the inspired air. 

The air, on inspiration, describes a half-circle on passing- through the nose 
from the entrance of the nares to the choana. It first impinges on the anterior end 
of the middle turbinate and is divided into two streams, one passing through the 


516. Paulsen: Mitth. d. Vereins Schleswig-holst. Arzte. Heft 10, 1885. 517. Zwaar¬ 
demacher: Die Physiologie des Geruchs. S. 50, 1895. 





ETHMOID LABYRINTH. 


325 


olfactory fissure, the other, which is smaller, beneath and through the middle nasal 
passage. On expiration the posterior extremity of the middle turbinate acts as a 
shield and diverts the main stream outward through the middle meatus. The 
devious passage thus taken by the air currents insures the greatest possible ab¬ 
sorption of heat and moisture before entering the larynx. 

JETIOLOGY AND PATHOLOGY. 

Before discussing the cause of ethmoidal disease we must con¬ 
sider the various pathological conditions to which it is suscep¬ 
tible. 518 These may be divided into: 

1. Acute catarrhal inflammation. 

2. Acute suppurative inflammation. 


Fig. 199.—Direction of air currents through the nose. Right side, lateral nasal wall. Left side, septum. 

S. Sphenoid sinus. F. Frontal sinus. C. Choanse. 

3. Chronic catarrhal inflammation. (Hyperplastic ethmoiditis.) 

4. Chronic suppurative inflammation. (Empyema.) 

5. Chronic catarrhal inflammation with suppuration.* 

1. ACUTE CATARRHAL INFLAMMATION. 

This condition occurs to a greater or lesser degree with every 
acute coryza, depending upon the length and severity of the attack. 

518. Ufi'enorde: Die HrKrantungen des JSiebbeins. Jena. 1907. 

*To Bosworth (Various Forms of Disease of the Ethmoid Cells, New York Med. 
Joum., Nov. 7, 1891) belongs the priority of first recognizing and describing the different 
affections of the ethmoid cells, as he anticipated Uffenorde by some sixteen years. This 
classification was the following: 

1. Myxomatous degeneration without purulent discharge. 

2. Extracellular myxomatous degeneration with purulent discharge. 

3. Purulent ethmoidities with polypi. 

4. Intracellular polyp without pus discharge. 

5. Intracellular polyp with pus discharge. 

This was later endorsed by Rice (Relations of Pathologic Conditions of the Ethmoid 
Region to Asthma. Trans. Am. Laryn. Assn., p. 91, 1899). It will be noted in Bos- 
worth’s classification that several of the divisions are in reality the same affection, thus 
number four and number one are practically identical, the former being an advanced con¬ 
dition of the latter, and, again, number two and number five represent different stages 
of the same pathological condition. 




















326 


THE ACCESSORY SINUSES OF THE NOSE. 


The mucosa of the uncinate process, bulla and external surface of 
middle turbinate become swollen, having the appearance of a 
myxomatous degeneration with punctiform hemorrhages on 
various parts of the surface. The interior of the cells shares in 
these pathological changes. Resolution occurs more slowly than in 
the general nasal mucosa. That this condition may result from 
irritation alone is shown by the results seen in the mucosa follow¬ 
ing resection of a portion of the middle turbinate. 

2. ACUTE PURULENT INFLAMMATION. 

Acute empyema of the ethmoid cells per se is, generally speak¬ 
ing, a uncommon affection, at least in our country. It is usually 
associated with acute frontal sinus empyema (anterior cells) or 
if arising idiopathically may be traced to one of the infectious dis¬ 
eases (influenza, dlptheria, scarlet fever, measles, etc.). Resolu- 

Scarlatinal infections of the ethmoid tend to spread toward the orbital wall 
and are so virulent that the underlying periosteum and bone are early involved. 
This accounts for the great tendency to break through into the orbital cavity or 
externally near the inner corner of the eye, thus causing a fistula which usually 
persists until the infected bony portion is either thrown off as a sequestrum or 
removed by operative means. The extent of osseus infection is usually small, 
although it may be so extensive as to lead to phlegmon of the orbit. This complica¬ 
tion is fortunately relatively rare. Schilperoort 518+ finding but three cases in 450 
of scarlatina. 

tion occurs more readily than in the sinuses proper on account of 
the relatively good drainage of each cell, together with the action 
of the cilia, which, on account of the small mass of secretion to 
be expelled, are not so taxed as in the larger cavities. 

During the later stages of a fresh coryza it is frequently observed that large 
masses of purulent secretion are continually blown from the nose with immediate 
relief of the “ stuffiness.” Much of the secretion has been thrown off from the 
ethmoid cells. 

In this form of disease the mucous membrane is deep red and 
covered with a thick purulent secretion. In contradistinction to the 
catarrhal type this form is directly due to micro-organismal 
invasion. 

Symptoms .—It is difficult to enumerate the precise symptoma¬ 
tology of acute ethmoiditis, for the reason that the disease is 
rarely met with dissociated from other conditions. In general, it 
may be compared to a particularly severe cold in the head. 
Absolute occlusion of nares, particularly in the superior portion 
between the eyes. (The inferior turbinates are sympathetically 
engorged.) Headache is, of course, constant, taking on a tense 
character with occasional neuralgic outshoots towards the deeper 
structures of the eyes; ocular symptoms are prominent as tender- 

518f. Schilperoort: Purulent Ethmoiditis in Scarlatina: Acta Oto-Laryngologica 

Vol. 1, P- 612, 1919. 



ETHMOID LABYRINTH. 


327 


ness of the bulb, pain on rotating, epijDbora, orbital neuralgia on 
reading or otherwise concentrating the gaze. Anosmia is marked 
ae long as the nasal obstruction exists. The general disturbances 
are analogous to those occurring during the course of a severe 
coryza. 

Diagnosis and Prognosis .—The diagnosis of these acute forms 
of ethmoiditis must be larg’ely conjectural, for the reason that any 
satisfactory rhinoscopic examination owing to the enormous 
swelling is out of the question. Adrenalin and cocaine do not act 
well in these affections; therefore, our means of ascertaining the 
precise conditions are greatly limited. As a matter of fact, the 
differential diagnosis between an acute ethmoidal disturbance and 
an acute cold in the head is an impossibility, as the two conditions 
are to all intents and purposes inse23arable. For practical purposes 
we might say that the condition is one of acute ethmoiditis when the 
cold in the general nasal cavity has abated, while the ethmoid 
appears yet to continue unduly inflamed. 

The prognosis is precisely the same as that of an acute coryza. 
One point, however, must be emphasized. Each attack predis¬ 
poses toward another, leaving the disintegration of the mucosa 
more and more marked, until a condition of chronicity develops, 
together with a marked tendency toward catching cold; there¬ 
fore, it is wise during the interim between attacks to make a 
comprehensive examination of this region with the view of ascer¬ 
taining and suppressing the cause of the discomfort. 

Treatment .—Acute catarrhal inflammation: The indications 
for the treatment of this affection are similar to those of acute 
catarrh, a frontal or maxillary sinusitis, except in this instance we 
have to combat inflammation in the interstices of numerous cells 
instead of one continuous cavity. For this purpose we observe 
the following rules: 

(1) The patient should be ordered to bed. 

(2) The blood should be depleted from the head by opening the 
bowels with 1/10 calomel and soda every hour until free purga¬ 
tion is established. 

(3) This may be assisted with a Dover's powder, followed by 
a hot mustard foot-bath. 

(4) Ice-bags should be applied to the head, covering the eyes 
and bridge of the nose. 

(5) Inhalations of vapor arising from hot water with tr. ben¬ 
zoin. comp., tablespoonful to quart. 


328 


THE ACCESSORY SINUSES OF THE NOSE. 


This treatment, if instituted early and energetically carried 
out, will usually cut short the attack. Local treatment, such as 
applications of adrenalin, cocaine, etc., are badly tolerated, as the 
after-effect only supplements the discomfort of the original con¬ 
dition and undoubtedly protracts resolution. 

Acute Suppurative Ethmoiditis .—A similar treatment to that 
outlined above is indicated. As the secretion is usually loosened by 
the vapor inhalations, operative measures are rarely if ever re¬ 
quired. If, however, such a contingency arises, resection of the 
uncinate process with ablation of the ethmoidal bulla may be 
demanded (see page 349). 

Occasionally a fulminating case may be encountered which resists all intra¬ 
nasal measures and rapidly invades the orbital structures causing oedema, swelling 
and great pain. Under these circumstances it is wise not to delay further, but per¬ 
form an external operation at the earliest possible moment, thus permitting free 
drainage externally. 518 * 1 

3. CHRONIC INFLAMMATION OF THE ETHMOID LABYRINTH. 

The ethmoid cells are subject to three different chronic in¬ 
flammatory processes, two being entirely separate and distinct, 
and the third a combination of these. They are: 

1. Chronic catarrhal inflammation (hyperplastic ethmoiditis). 

2. Chronic suppurative inflammation (empyema). 

3. Chronic catarrhal inflammation with suppuration. 

^Etiology. —In contradistinction to empyema, the causative 

factor for hyperplastic ethmoiditis depends rather upon a pro¬ 
tracted and more or less continual disturbance in the nutrition 
(circulus vitiosus) of the ethmoidal capsule than upon inflamma¬ 
tory changes with bacterial invasion. Mechanical causes would 
seem to be pre-eminent. Repeated attacks of coryza, each one 
leaving greater changes in the mucosa, certainly contribute to the 
ultimate formation of polypoid tissue. Particularly wide nares, 
allowing the inspired air to act as a distinct irritant, are often 
found associated with polypoid degeneration of the operculum of 
the middle turbinate. 

It is a well-known fact that once polypoid tissue is formed in 
the nose, just that much greater tendency the mucosa exhibits 
to transmit this hyperplasia to neighboring cells; therefore, the 
longer the process has been standing, the greater in all probability 
the polypoid infiltration. 

Pathology. 519 — The continual slight irritation of a certain por- 

518a. Frank: A Case of Fulminating Ethmoiditis with Metastasis. Laryngoscope 
p. 425, July 1919. 519. Skillern: The Comparative Pathology of Hypertrophic and Sup¬ 
purative Ethmoiditis. Journ. Am. Med. Assn., Dec. 17, 1910. 



ETHMOID LABYRINTH. 


329 


tion of the mucosa causes at first hyperaemia with subsequent out¬ 
flowing of serum into the interstitial spaces of the connective tissue. 
If the irritation he mild the hypertrophy will tend to spread itself 
over a broad area, gradually losing its polypoid character in 
the surrounding tissues. If, however, it he great, the continual 
collection of serous elements, assisted by the force of gravity, 
will soon cause the appearance of a true mucous polyp. These 
changes occur principally upon the anterior end of the middle 
turbinate, along the uncinate process or in the region of the eth¬ 
moidal bulla (floor of ethmoid capsule). When the changes occur 
in the cells proper, some interference has taken place in the col¬ 
lateral circulation from partial occlusion of their ostia or direct 
continuation of the process from one cell to another. 

To E. Woakes, of London, belongs the distinction of first calling attention 
to the relation between nasal polyps and ethmoid disease . 520 This author con¬ 
sidered the polyp as symptom and result of a necrosing condition of the under¬ 
lying ethmoid bone and attempted to prove his assertion by microscopic observa¬ 
tions. He was unfortunately assailed on all sides by his colleagues , 521 so that no 
further elucidation of the subject was accomplished until Hajek 623 made systematic 
microscopical examinations of not only the polypoid tissue, but also the place of 
their attachment to the bone. The findings of this investigator werq totally dis¬ 
similar to those of Woakes, at least as far as their translation was concerned. 
Hajek found the polyp took its inception in the external layer (columnar) of the 
epithelium and worked its way inward, finally attacking the bone. The osseous 
changes were those of apposition and reabsorption, but not the slightest trace of 
carious or necrotic process was anywhere to be observed. This proved that the 
name, necrosing ethmoiditis, as given by Woakes to the pathological process, was 
decidedly a misnomer, as what Woakes considered necrotic bone, from examination 
with the sound, was in reality a condition of osteo-porosis. Hajek’s findings were 
later substantiated by Cordes 523 and Uffenorde ; 524 hence, polyps and polypoid hyper¬ 
trophies are due to external causes, and the many changes in the underlying bony 
structures are the result and not the cause of these pathological conditions. 

Microscopic Examination .—The external lining membrane be¬ 
fore polypoid changes occur shows considerable round cell and leu¬ 
cocytic infiltration. No metaplasia of the ciliated epithelium into 
squamous occurs until the tissues assume a marked polypoid char¬ 
acter except over the area which has been subjected to irritation. 
There is marked connective-tissue formation beneath the base¬ 
ment membrane, the meshes of which become dilated and filled 
with exudate. The mucous glands are primarily hypertrophied, not 
infrequently showing enormous cystic dilatation of their acini. The 

520 . Woakes: Necrosing Ethmoiditis. Brit. Med. Joum., April 14, 1885. Lancet, 
July 18-25,1885. 521. Pathology of Necrosing Ethmoiditis. Brit. Med. Journ., March 12, 
1892, June 10, 1893. Heath, Martin, Watson, Browne, and Taylor: Brit, Med. Journ., 
Dec. 10, 19, 22, 1892, and Jan. 3, 16, 1893. 522 . Hajek: Ueber Die path. Verand. d. 
Siebbeinknochen, etc. Arch. f. Lary., Bd. 4, S. 277, 1896. 523 . Cordes: Ueber die Hyper- 
plasie, die Polypose Degeneration der Mittleren Muschel, etc. Arch. f. Lary., Bd. 11, S 
280 , 1900. 524 . Uffenorde (518), S. 35. 




330 


THE ACCESSORY SINUSES OF THE NOSE. 


blood-vessels are surrounded by leucocytes and soon begin to 
atrophy. The periosteum is hypertrophied and shows fibrous de¬ 
generation along the bone, numerous bone-cells range themselves, 
some forming new osseous tissue (osteoblasts), others causing re¬ 
absorption (osteoclasts). In well-marked cases the osteoclasts 
appear to predominate. These pathological changes are transmitted 
directly through the bone to the periosteum and subjacent tissues. 

Symptoms, —In the earlier stages of hyperplastic ethmoiditis 
a condition resembling chronic coryza predominates. Every ex¬ 
posure to cold, draughts, damp feet, etc., brings on attacks of 
sneezing, increased watery secretion from the nose, ocular mani¬ 
festations, etc. When the disease has become outspoken one of 
the principal symptoms is the headache, which is marked in the 
region of the nasal base above and below the eyes and often radiat¬ 
ing toward the temples. It is not constant, but seems to depend 
largely upon the state of congestion of the head. Occasionally the 
pain is so intense as to simulate an idiopathic neuralgia and lead 
to resection of a nerve. 525 Unlike pain from the sinuses, it is not 
so markedly affected by indulgence in tobacco or alcohol or by 
stooping or sudden jarring. A marked feeling of fulness is present 
in the upper portion of the nose, and not infrequently the patient 
complains of intra-ocular pressure. 

Secretion: The exudate may, on account of its abundance, be 
one of the most prominent and annoying symptoms. It is of thin 
watery consistency, straw colored, leaving no perceptible stain 
upon the handkerchief. During attacks of acute coryza it often 
assumes a purulent consistency, but after the disappearance of 
the cold resumes its former appearance. 

Olfactory Function: Disturbances in the sense of smell are 
common on account of the occlusion of the olfactory space by the 
encroachment of polypoid tissue. Anosmia is naturally most fre¬ 
quently met with, although occasionally a subjective unpleasant 
musty odor is now and then perceived by the patient. This is 
undoubtedly due to stagnation of the secretion in some of the 
interstices behind the polypoid swellings, with invasion of 
saprophytic micro-organisms. An unpleasant taste in the mouth 
is often present in the morning, due to stagnation and fermenta¬ 
tion of the secretion, which has collected in the choanse during 
the night. 


525. Marquis: Non-suppurative Ethmoiditis. Laryngoscope, p. 12, 1911. 



ETHMOID LABYRINTH. 


331 


Pharyngeal and Bronchial Symptoms: Certain disturbances 
met with in the pharynx are often associated with this disease. 
Granular hyperplastic pharyngitis, particularly behind the pos¬ 
terior tonsillar pillars, is common. Hypertrophy of the tonsils, 
as well as Eustachian catarrh, may he classed as concomitant 
affections. 

By far the most common bronchial affection occurring with 
hyperplastic ethmoiditis is asthma, an association which has long 
been recognized by laryngologists. How far this may have a 
bearing upon the ethmoidal disease is well shown by the numerous 
cures reported after removal of the diseased ethmoidal struct¬ 
ures. 52 ^ The precise relation between nasal polyps and asthma 
has, as far as I am able to learn, not been clearly explained. 
Bronchitis in various degrees also accompanies this disease, and 
in Uffenorde’s statistics occurs in about 30 per cent, of all cases. 

Orbital Symptoms: In contradistinction to sinus empyema the 
eye symptoms connected with the hyperplastic form of ethmoiditis 
are usually of mechanical origin. In the former the reabsorption 
of pus plays a prominent role, while in the latter the pressure 
exerted by the new tissue formation, together with the consequent 
disturbances in circulation, are the exciting cause. 

The subjective symptoms consist of scotoma, neuralgic pains 
in the bulb, ciliary neuralgia and photophobia. In severe cases 
vasomotor disturbances, such as liyperaemia of conjunctiva and 
oedema of eyelids and periorbital tissues, may occur. The appear¬ 
ance of these reflex neuroses is hut to be expected, when one 
recalls that the orbital and nasal cavities are supplied by the 
same sensory nerves. 

Diagnosis.— When the general symptoms point to ethmoidal 
disease our first thought would be to examine the middle turbinate 
and as much of the capsule as possible. For this purpose a long 
Killian speculum is necessary. The blades should be introduced be¬ 
tween the uncinate process and middle turbinate, and forced apart, 
thereby giving us a good view of the bulla and surrounding tis¬ 
sues. A sound must now he employed to ascertain the condition 
of the mucosa. Frequently the base of the bulla will be lined with 
pearl-like polyp buds, which assume considerable size after the 
turbinate has been infracted. It is impossible to estimate the 
degree of polypoid changes that have taken place within the cap¬ 
sule until the cells are laid bare. Posterior rhinoscopy is now 

525a. Brown: Asthma Associated with Ethmoidal Disease. Ann. Otol. Rhin. and 
Laryng., p. 397, 1917. 




332 


THE ACCESSORY SINUSES OF THE NOSE. 


applied to determine the condition of the cells of the superior 
nasal passage. The maxillary sinus should be punctured to ex¬ 
clude empyema of that cavity. If no signs of purulent secretion 
or crusts he present, yet polypoid degeneration of the ethmoid 
mucosa apparent, we can safely make a diagnosis of chronic 
hyperplastic ethmoiditis. 

Treatment.— No conservative treatment will suffice after the 
development of this disease. A certain amount of tissue must be 
removed, according to the extent of the inflammation. Two forms 
of the disease are recognized: 1. Large polyp formations, few in 
number, with circumscribed areas of inflammation. 2. General 
polypoid inflammation of more or less 
of .the entire ethmoid capsule. 

1. Let us suppose we have a pa¬ 
tient with several large polyps hang¬ 
ing from beneath the middle turbinate 
and have satisfied ourselves that no 
purulent process is present. Natu¬ 
rally our first thought is to remove the 
polyps. To introduce a snare and re¬ 
move them without further investiga¬ 
tion is bad surgery, for in this way 
the subsequent hemorrhage will make 
it impossible to learn their exact 
source or to ascertain the extent of 
the polypoid degeneration. W e 
should endeavor to follow up the 
polyps to their attachment by exam¬ 
ining the ethmoidal capsule after re- fig. 200.—Lan ge ;s frontal sinus and ex¬ 
traction of the middle turbinate. If 

the polyps he so large or numerous that this is impossible, it is 
almost certain that the greater portion of the ethmoid is diseased; 
however, in any case an attempt should he made to learn their 
origin. Suppose it has been found that they spring from the re¬ 
gion of the uncinate process and bulla. We can choose between 
two lines of operating: (1) simple ablation of the polyps; (2) ab¬ 
lation of polyps and removal of all polypoid tissue. 

(1) Simple Ablation of Actual Polyps: The parts must 
be thoroughly cocainized and made bloodless with the cocaine- 
adrenalin solution. The loop of the snare should be made to 
encircle the polyp, and the end of the tube carried up around 



ETHMOID LABYRINTH. 


333 


the base as high as possible by working the wire with a wabbling 
motion, gradually constricting the loop until firm resistance 
is encountered. The wire is now slowly tightened until it is 
felt that any further constriction will cut through the neck of 
the polyp. After making certain that it has firm hold on the 
tissue, the entire instrument is suddenly jerked out of the nose. 
This procedure causes no particular pain, and at the same time, 
instead of merely severing the polyp from its attachment, leaving 
a portion of the neck behind, it often removes a considerable part 
of its bony attachment, thereby obtaining tissue which, if left 
behind, would serve as a means for the recurrence of the hyper¬ 
plasia. This manoeuvre is repeated until all the visible polyps have 
been removed. 

(2) Ablation of Polyps with the Removal of all Polypoid 
Tissue: The secret of the successful performance of this operation 
depends upon the thoroughness of the ischaemia produced; there¬ 
fore, in addition to the cocainization, pure adrenalin chloride 
should be sprayed up into the ethmoid region after the parts have 
been cocainized. Twenty minutes should elapse from the time of 
the first application of adrenalin to the inception of the opera¬ 
tion. The polyps are removed with the snare as before by abla¬ 
tion. If any bleeding occur, it can be controlled by the application 
of cotton pledgets saturated with pure adrenalin chloride. The 
double Grunwald forceps, which seize but do not bite, are now 
used, and, always working beneath the middle turbinate, the 
osseous tissue forming the base of the polyps is removed piece¬ 
meal until healthy tissue is reached. This is easily recognized by 
the whitish, tense, thin membrane which lines the normal ethmoid 
cells. Several cells may be resected as described on page 350. In 
this manner, by slow and careful work, incipient hyperplastic 
ethmoiditis is often effectually combated with preservation of the 
middle turbinate. 

If it is found necessary to remove a portion of the middle tur¬ 
binate in order to expose the floor of the ethmoid capsule, the fol¬ 
lowing method will be found of peculiar advantage. 

Sluder’s Method. 5251 * 

(1) A knife similar to Hajek’s is introduced between the middle 
turbinate and the septum “on the flat,” then turned so that the 
point engages in the anterior end of the superior nasal passage. 
(Fig. 200a.) 

525b. Sluder: A Method for the Removal of the Whole or a Part of the Middle Tur¬ 
binate. Journ. Am. Med. Assn., June 29, 1907. 




334 


THE ACCESSORY SINUSES OF THE NOSE. 


(2) The knife is drawn forward with a slight upward pressure 
until it has completely severed the anterior attachment of the middle 
turbinate above. 

(3) The wire loop of a nasal snare is now passed over the de¬ 
tached portion and as much of the turbinate removed as desired. 
(Fig. 200 b.) 

2. General Polypoid Inflammation of the Ethmoid Capsule .— 
This form of the disease is merely an advanced stage for the for¬ 
mer, although it often occurs without the primary formation of 
polyps of any considerable size. During the advanced stadium 
the polyps may be so numerous as not only to occlude the nares 
but to cause a widening of the nasal arch. 

A ease of this character has been reported in which the polypoid mass was re¬ 
moved intact and measured four inches long, one and one-half inches wide anter¬ 
iorly and posteriorly and one inch in thickness. 52 ® 0 

The only effective treatment available for this condition is com- 
plished by the method described on page 349 but is better ac¬ 
complished by the method recently advocated by Ballenger. 526 
by the method recently advocated by Ballenger. 526 

Ballenger’s Method: The rationale of this procedure is to 
exenterate the ethmoid labyrinth in toto with the least possible 
number of incisions and in the shortest possible time. The author 
does it as follows: 

(1) Cocainization and adrenalization as before. 

(2) A Ballenger knife is introduced beneath the bulla to the 
posterior attachment of the middle turbinate and pulled forward, 
cutting along the lamina papyracea and as far up as possible. This 
incision is repeated until the capsule is free from the orbital plate. 
Care must be taken not to injure this plate at the anterior end of 
the incision near the inner angle of the eye. 

(3) The angular knife (Fig. 201) is now introduced until the 
short blade rests against the anterior wall of the sphenoid, the 
long blade occupying the cut previously made. The handle is now 
depressed and the short blade forced through the ethmoid cells 
slightly below their attachment to the frontal bone. 

On performing these cuts the knife must be brought forward with a wabbling 
motion, thereby fracturing the thin plates of the ethmoid cells in its progress forward. 

The knife is drawn completely forward until it emerges from 
the nose, leaving the severed portion of the capsule lying free in 
the nares. (Fig. 202.) 

525c. Orton: An Unusually Large Polypus of the Ethmoid. Laryngoscope, p 684., 1917. 
526. Ballenger: Diseases of Nose, Throat and Ear, p. 233,1909. 




Fig. 200a. —Sluder’s method—Knife incision. 



Fig. 2006.—Sluder’s method—Removal of turbi¬ 
nate with snare. 





Fiq. 201.—Ballenger’s ethmoid knives. 









































ETHMOID LABYRINTH. 


335 


(4) Remove fragment with stout pair of forceps. In this man¬ 
ner polyps, hypertrophied tissue, et al., are removed in one piece, 
the capsule being entirely ablated. Bleeding is rather smart for 



Fig. 202. —Exenterating ethmoid capsule en 
masse with the Ballenger right-angle knife. The 
ethmoid capsule with the middle and superior tur¬ 
binate has been severed from its attachment and has 
dropped on to the floor of the nose. 


a few moments, hut ceases 
shortly of its own accord. The 
attending pain is not great and 
the entire operation requires 
but a few moments. 

When this method was introduced, 
considerable opposition was encountered 
from all sides, many rhinologists con¬ 
sidering it entirely unjustifiable. 527 I am 
free to admit that I also shared in this 
opinion, but after the many excellent 
results obtained without even an un¬ 
toward symptom the operation has now 
become a routine practice with me. It 
should not be particularly painful to 
the patient, and any tendency toward 
dryness in the nose after healing seems 
to be successfully prevented by compen¬ 
satory swelling of the inferior turbinate. 

After-treatment consists 
merely in keeping the parts free 
from crusts and debris, which 


can be accomplished by daily irrigation with warm sterile normal 
salt solution, followed by insufflation of bismuth-formic-iodide pow¬ 
der. Tampons of any sort to control hemorrhage are usually 
superfluous, and only add to the discomfort of the patient. 


4. CHRONIC SUPPURATIVE INFLAMMATION. (EMPYEMA.) 

Suppurative processes in the ethmoid cells may occur in two 
forms: (1) open or manifest empyema; (2) closed-in or latent em¬ 
pyema. In the first instance the purulent secretion forming in the 
cells escapes through the ostia and appears in the nose, while in 
the latent variety some occlusion prevents the pus from escaping, 
so that it gradually is secreted under pressure until it bursts or 
is evacuated by artificial means. 

^Etiology. —Suppuration in the ethmoid cells usually is but an 
accompaniment of empyema in one of the larger cavities; how¬ 
ever, it may occur as a separate process. Acute infectious diseases 


527. Ballenger: The Exenteration of the Middle Turbinate Body and Ethmoid Cells 
en masse. Trans. Am. Lary., Rhin. and Otol. Soc., p. 497, 1909. 




336 


THE ACCESSORY SINUSES OF THE NOSE. 


seem to exert a peculiar influence toward ethmoidal suppuration, 
in all probability by lowering the vitality of the lining mucosa. 

When one considers that at least half of the respiratory mucosa belongs to the 
ethmoid capsule it is rather a wonder why cases of suppuration in these cells are not 
more frequently encountered. 

Another aetiological factor of no little importance is the forcible 
blowing of the nose during a coryza, thus forcing pus and inflam¬ 
mation into cells that would otherwise remain normal. (Roe.) 

Suppuration in the ethmoid cells not infrequently follows 
packing the nose after an intranasal operation. Cauterization 
with the actual cautery after the removal of polyps often causes 
purulent infection, as the direct result of the intense inflammatory 
reaction. 

As the maxillary antrum or the frontal sinus or both are often coaffected, it 
is frequently a question which has been the primary seat of the disease. Luc 
believes the ethmoidal cells are always secondarily affected either from the frontal 
or maxillary sinus. 

It is also possible for infection of the ethmoid cells to occur 
through the lamina papyracea following orbital abscess of idio¬ 
pathic origin. If we revert a moment to the anatomy and con¬ 
sider the delicacy of the orbital plate separating the ethmoid cells 
from the orbital structures, it is small wonder that such an infec¬ 
tion readily occurs. 

Pathology.— Chronic suppuration in the ethmoid cells is in¬ 
variably due.to bacterial infection. The changes in the mucosa 
are similar to those in empyema of the large sinuses, being thick¬ 
ening with a marked formation of fibrous tissue. There is a 
marked tendency toward occlusion of the ostia through swelling 
of the mucosa, particularly in the smaller cells—a condition due 
to the especial tenderness and looseness of the ethmoid mucosa. 
Round-cell infiltration is prominent; gradual proliferation of the 
epithelium occurs, which in severe cases is often absent in spots, 
being replaced by granulation tissue. 


Hyperplastic Type. 

Metaplasia of ciliated epithelium into 
squamous only where parts have come 
into contact with other structures. 

Meshes of subepithelial connective 
tissue dilated. 

Round cell infiltration scanty. 

Glands hypertrophied primarily. 

Reabsorption changes in bone pre¬ 
dominate. 


Suppurative Type. 

General metaplasia where secretion 
comes into contact with mucosa. 

Subepithelial connective tissue shows 
fibrous formation. 

Round cell infiltration well marked. 
Glands primarily atrophied. 

Apposition of bone predominates. 


ETHMOID LABYRINTH. 


337 


Symptoms. —It is impossible to enumerate a given set of symp¬ 
toms that will apply equally well to all cases of suppurative 
ethmoiditis, as, perhaps, no one affection will exhibit such a 
variegated clinical picture. It not only depends upon the virulence 
of the infection and the extent of the process, but upon the dis¬ 
position of the individual as well. The suppuration usually shows 
a marked tendency to run its course without causing a great deal 
of subjective discomfort, and, as Hajek well says, the patient 
often comes to us complaining rather of pharyngeal or laryngeal 
disturbances than of trouble located in the nose. Another point 
to be remembered is that ethmoidal suppuration is usually com¬ 
bined with frontal or maxillary sinus empyema, and in such cases 
it is difficult to differentiate the symptoms caused by these from 
those of ethmoidal derivation. 

The headache present in these cases shows a marked difference 
from that caused by the hyperplastic variety unless associated 
with polyposis. In the uncomplicated form, where free drainage 
exists, there is often no history of headache whatsoever, while in 
the closed-in variety, where stagnation has occurred, the head 
pains are sometimes unendurable. During an acute exacerbation 
of a chronic ethmoidal suppuration the headache is often diffuse. 
The typical region for the localization of the pain in ethmoidal 
disease appears to be over the root of the nose and directly on the 
vertex, occasionally radiating downward into the mastoid proc¬ 
esses. Deep-seated pain in the eyes or tension on the bulb is not 
present unless stagnation and pressure occur. 

Secretion .—The exudate in contradistinction to that emanating 
from hyperplastic ethmoiditis is distinctly purulent, invariably ex¬ 
hibiting the greatest tendency toward drying and forming crusts 
not only in the nares, but in the pharynx and even the larynx. The 
quantity secreted depends, as before, upon the extent and degree 
of the inflammation; sometimes in the same case it may continue 
profuse for days, then suddenly reduce itself to a minimmn, only 
to break forth violently at the first acute exacerbation. Pus cells, 
however, may always be discerned with the microscope—a condi¬ 
tion which is not often present in the exudate from the hyper¬ 
plastic form. 

Olfactory Disturbances .—Anosmia is frequent, being due to 
two conditions: 1. Swelling of the middle turbinate, thus occluding 
the olfactory fissure. 2. Anatomical changes due to degeneration 
of the terminal olfactory filaments from the constant bathing in 
22 


338 


THE ACCESSORY SINUSES OF THE NOSE. 


purulent secretion, and cacosmia is the rule rather than the ex¬ 
ception, and differs from the sourish or musty smell observed 
associated with hyperplasias, in that the odor is distinctly fetid. 
This is undoubtedly caused by putrefactive changes in the various 
foci of pus, which have become isolated in the numerous 
interstices of the ethmoid capsular wall. No secretion is observed 
in the closed type. 

The pharynx is hypersensitive, due to the constant rasping 
and hawking, particularly in the morning, in order to clear the 
throat of the crusts and particles of dried secretion which have 
formed during the night. Nausea and vomiting can easily ensue 
from this cause, giving the appearance of a gastric affection. 

Rhinoscopic Examination .—It will he apparent that secretion 
is present by the signs of crust formation, particularly around 
the external nares. The middle turbinate is hypertrophic, and 
traces of pus are visible between it and the lateral nasal wall. 
If this turbinal be infracted a quantity of secretion often wells 
out from the middle nasal passage, and if the uncinate process 
appears swollen it is almost pathognomonic of the disease. 

Polyps in the recent cases are not present, and, when due to 
the irritation from the constant bathing with the purulent secre¬ 
tion, are large and spring from those portions of the ethmoid 
which are low down and prominent (uncinate process, bulla and 
middle turbinate). In hyperplastic ethmoiditis without suppura¬ 
tion they are small and numerous, and occupy the various eth¬ 
moidal cells. The inferior turbinate is often distinctly atrophic. 

Pharyngitis sicca is always present in advanced cases, being 
due to the evaporation and irritation of the secretion which con¬ 
tinually finds its way into the pharynx during sleeping hours. 
Laryngeal affections, as with the true sinuses, may also occur as 
a result of the irritation from the down flowing secretion. 
Chronic dyspepsia has also been reported as a sequel of this 
condition. 

Orbital symptoms are uncommon with suppurating ethmoid¬ 
itis when the drainage is not interfered with. In long-standing 
cases symptoms of auto-intoxication from reabsorption of toxins 
or transmission through the venous system may occur, but as yet 
such cases have not come under my observation. 

Diagnosis.— The diagnosis of free purulent suppuration in the 
anterior ethmoid cells is not usually a matter of great difficulty, 
provided the proper examinations are made. The first examina- 


ETHMOID LABYRINTH. 


339 


tion may not suffice to attain this object, but repeated endeavors 
will surely bring to light the source of the secretion. Every atten¬ 
tion must be paid to the lesser symptoms, such as crusts in the 
middle nasal passage, unnatural hypertrophies in the region of the 
uncinate process, etc. Let us, however, take up the diagnosis in a 
systematic manner. Suppose on examination we discovered an 
enlarged middle turbinate and traces of pus in the middle nasal 
passage, both symptoms of disease of any or all of the anterior 
sinuses. Our first thought is to insert the long-bladed Killian 
speculum and obtain a view of the middle nasal passage and 
contained structures. On the application of this instrument more 
pus is seen to issue from the depths of this fossa. Wb now thor¬ 
oughly wash out the nose with the saline solution so as to cleanse 
the cavity from all free pus, crusts and detritus, and observe 
carefully whether the secretion immediately reappears. This 
symptom being positive, we make the customary puncture of the 
antrum beneath the inferior turbinate with a negative result. 
Turning next to the frontal sinus, we sound and catheterize this 
cavity, ultimately washing it out with our salt solution. If no pus 
appears in the returning fluid a tentative diagnosis of ethmoidal 
suppuration can be made. It is necessary, however, to go still 
further and ascertain the exact source of the secretion. Resec¬ 
tion of a portion of the middle turbinate will probably be 
demanded not only for diagnostic purposes, but to create suffi¬ 
cient drainage as well. After healing of the wound has occurred 
it may be possible to directly observe the purulent matter exud¬ 
ing from the middle nasal passage. This with the reappearance of 
crusts in this locality which conceal foci of pus, together with 
the exclusion of maxillary or frontal disease, will substantiate 
the diagnosis. 

Transillumination .—Although this method of diagnosis has 
its devotees, 528 529 we have found it thoroughly unreliable in eth¬ 
moidal suppuration. This is probably due to the fact that it is 
impossible to place the light in such a position as to send the rays 
through the bulla and surrounding structures. At best the 
shadows in the normal individual are indefinite, and in disease 
one is obliged to call on the imagination in order to perceive a 
definite picture. We have long since abandoned this procedure 
in examination of the ethmoidal region. 


528. Rault (142). 529. Luc: Leconssur lesuppuration de Toreille, etc., p. 347,1910. 




340 


THE ACCESSORY SINUSES* OF THE NOSE. 


The X-ray not only acquaints one with the condition of the ethmoid cells, but the 
exact location of the purulent collection as well. This is particularly exemplified if 
one has the exposures so taken that they may be used as stereoscopic plates. By this 
method the ethmoid capsule and cells appear in natural form, although transparent, 
thereby simplifying the picture to such an extent that it can be read and interpreted 
by any one familiar with the anatomy of this region. 

Abnormal difficulties in the diagnosis, such as the maxillary sinus acting as a 
reservoir for pus from the ethmoid cells, suppurating orbital cells, have been dis¬ 
cussed under the frontal sinus. 


DIFFERENTIAL DIAGNOSIS. 


Chronic Hyperplastic Ethmoiditis. 

Often bilateral. Secretion clear and 
watery. 

Never crust formation. 

Headache most prominent symptom. 

Ophthalmic manifestations due to pres¬ 
sure of hypertrophic mucous mem¬ 
brane on vessels. 

Gastric disturbances absent. 

Neurasthenic symptoms predominate. 


Chronic Purulent Ethmoiditis. 
Usually unilateral. Secretion purulent. 

Always crust formation. 

Headache often light or absent. 
Ophthalmic manifestations due to infec¬ 
tion from purulent secretion. 

Gastric disturbances frequent. 
Neurasthenic symptoms not marked if 
flow of secretion be free. 


CLOSED-IN OR LATENT EMPYEMA. 

This affection is caused by the primary infection of a cell, whose 
ostium during the course of the disease has by swelling of its own 
mucosa or the coaptation of a neighboring structure become closed, 
the suppuration within the cell continuing. 

Under these circumstances one of four things must occur: 
1. The inflammation subsides with subsequent absorption of the 
secretion. 2. The secretion continues up to a certain stage, then 
remains dormant. 3. The inflammatory products continue to be 
secreted with dilatation and ultimate rupture of the cell. 4. The 
formation of a mucocele. 

1. Resolution with absorption of inflammatory secretion: This 
can occur only in the presence of germs which by successive growth 
gradually lose their virulence. The frequency with which this 
occurs is a matter of surmise, as after a length of time it would be 
impossible to ascertain on the autopsy table whether any patho¬ 
logical changes had taken place in a given cell which had thus under¬ 
gone resolution. 

2. Secretion forming and then becoming latent: This form 
of purulent ethmoiditis results from repeated attacks which 
finally produce a semi-permanent closure of the ostium. The 
inflammation does not appear severe enough to cause dilatation 
of necroses of the walls, neither is it absorbed, but remains in a 


ETHMOID LABYRINTH. 


341 


dormant state. A certain amount of drainage occurs, for at long 
intervals the affected cells empty themselves into the nose. 
Usually but few cells are affected, the most frequent being those 
of the bulla. The diagnosis of this variety, particularly from 
an empyema of the frontal sinus, is very difficult, and only by 
repeated examinations with the free use of the sound is one able 
to determine definitely the source of the secretion. 

3. Empyema with dilatation (pyocele): This is hut an ad¬ 
vanced form of the latent variety in which the closure is absolute, 
the dilatation resulting from the pressure of the continued secre¬ 
tion of the purulent products. The disease often is confined to one 
cell, which, in dilating, encroaches upon the walls of the neighbor¬ 
ing cells, absorbing them in its progress until a considerable por¬ 
tion of the ethmoid capsule is hollowed out into one large cavity. 
Four seats of predilection occur: (1) the free end of the middle 
turbinate; (2) the middle turbinate in its entirety; (3) the bulla 
ethmoidalis; (4) the posterior ethmoid cells situated beneath the 
superior turbinate. 

(1) A congenital middle turbinate cell must he present for this 
pathological process to take place. On rhinoscopic examination 
the middle turbinate appears to balloon downward, occupying 
much of the middle nasal fossa. (Fig. 203.) When pressed on 
with the sound it gives one a parchment-like impression. The 
contents are purulent, sometimes containing cheesy flakes. 

It is difficult to determine—unless the case has been followed up—whether 
dilatation has occurred through the internal pressure of the secretion or whether 
simple infection has taken place in physiologically enlarged cells in the middle 
turbinate. It is, however, only of theoretical interest, as the therapy is precisely 
the same in either instance, i.e opening at the lowest extremity with complete 
evacuation of the contents. 

On opening this enlargement with the hook and Griinwald 
forceps it will be noted that the cavity only extends upward as 
far as the attachment of the turbinate to the body of the ethmoid 
capsule. Information as to the true condition which confronts us 
will be at once obtained by the character of the contents. The 
lining mucosa of the cavity exhibits the characteristics of any 
purulently inflamed ethmoid cell. 

(2) When the entire middle turbinate is the seat of a pyocele 
the superimposed ethmoid cells are continuous with that of the 
turbinate, forming a large cavity which extends from its tip to 
the frontal wall of the cribriform plate. (Fig. 204.) Rhinoscopic 


342 


THE ACCESSORY SINUSES OF THE NOSE. 


inspection will only show the enlarged extremity of the turbinate, 
but on opening with a hook and using a sound the condition will 
at once become clear. 

(3) Purulent dilatation of the ethmoidal bulla. This form con¬ 
sists of a purulent collection in the cells of the bulla which ex¬ 
tends to the orbital plate. The bulla projects outward into the 
middle nasal passage, often reaching the septum, forcing the 
middle turbinate inward and upward in its progress. (Fig. 205.) 
Rhinoscopic examination reveals a picture which is often difficult 
to solve correctly. The dilated bulla occupies the position of a 
swollen turbinate, the latter structure being often completely 
hidden from view. A differential diagnosis is for the most part 



Fig. 203—Cell in middle 
turbinate filled with pus. 
Remaining portion of the 
ethmoid capsule unaffected. 
(After Hajek.) 


Fig. 204.—Middle tur¬ 
binate and superior ly¬ 
ing cells filled with pus. 
(After Hajek.) 


Fig. 205.—Bulla filled 


with pus. Remaining por¬ 
tion of ethmoid unaffected. 
(After Hajek.) 


impossible until the dilatation has been completely removed, 
when the turbinate will appear in situ. Confusion of this patho¬ 
logical condition with a normally enlarged ethmoidal bulla will 
hardly occur, as in the former instance some pathological changes 
are always present in the affected nares. 

It must be remembered, when considering these forms of dila¬ 
tation, that in no instance are they arbitrarily confined to the 
boundaries mentioned. In perhaps the majority of cases the 
process embraces a large portion of the ethmoid labyrinth, 
regardless of the individual structures. The process of dilata¬ 
tion continues until rupture occurs; therefore, it depends entirely 
upon the resistance of the walls as to the size and extent of the 
cavity. 

4. Mucocele of ethmoid labyrinth: A mucocele may occur in 





ETHMOID LABYRINTH. 


343 


either the anterior or posterior cells, although the former variety 
is by far the most common. It is characterized by a swelling 
at the superior internal portion of the orbital cavity, which 
progresses slowly without any symptoms of inflammation. The 
difference in the situation of the frontal and ethmoidal swelling 
may be too slight to be of any real differential diagnostic value. 
The protrusion is rounded, even, and, in the beginning, of bony 
hardness. The overlying cutaneous tissues show no changes from 
that of the surrounding skin. 

As the swelling progresses (sometimes requiring months and 
even years) the osseous walls become very thin from reabsorp¬ 
tion until at the most prominent part a distinct fluctuation is 
observed. The permanent oedema of the eyelid assumes greater 
proportions, and the eyeball becomes very gradually dislocated 
downward and outward until in very old cases it is forced far out 
of the socket. Spontaneous rupture can now occur. Within the 
nose a bulging of the ethmoid capsule toward the septum, with 
the formation of a smooth, rounded tumor, occurs, which shows 
decided elasticity when pressed upon by the sound. Pain in the 
eye is sometimes noted after the swelling has encroached upon 
the orbital structures, although it assumes more the sensation of 
a feeling of pressure and tension. 

The contents of these cystic structures is usually of a thick, 
mucoid consistency, variable as to color, quite sterile, and some¬ 
times difficult to remove on account of its cohesive qualities. 

As regards sterility micro-organisms have occasionally been found, but upon 
culture were shown to be devoid of virulency. Microscopical examination shows 
the contents to be composed of fatty degenerated epithelial cells, detritus, a few 
red and white blood-cells, and cholesterin crystals. 

As with the frontal sinus, it is not necessary that the ostium 
be occluded in order that a mucocele should form, as the contents 
are often too thick to escape. This would account for the not 
infrequent history of occasional discharge into the nose. 

The middle turbinate may be the seat of a mucocele. Under 
such circumstances the symptoms will be similar to those asso¬ 
ciated with an ordinary cystic enlargement in this locality. An 
opening at the most dependent portion will give immediate infor¬ 
mation as to the character of its contents. 

The posterior ethmoidal cells have been reported as the seat 
of a mucocele. When this takes place the swelling occludes the 
posterior nasal passages and may extend into the choana. This 


344 THE ACCESSORY SINUSES OF THE NOSE. 

condition, nnassociated with a similar affection of the anterior 
cells, must he one of extreme rarity. The simultaneous occur¬ 
rence of a mucocele on both sides of the ethmoid has also been 
observed. 530 


Mucocele. 


Pyocele. 


Growth extremely slow. 

No inflammatory symptoms. 
Tenderness absent. 

Firmness on palpation. 

Mild orbital complications. 
Puncture shows mucoid substance. 
Secretion sterile. 


Growth rapid. 

Inflammatory symptoms predominate 
Tenderness marked. 

Fluctuation. 

Severe orbital complications. 
Puncture shows pus. 

Secretion infected. 


When infection of a mucocele occurs a pyocele results. 

5. CHRONIC HYPERPLASTIC INFLAMMATION WITH SUPPURATION. 

This classification has found considerable opposition, 531-532 
most observers contending that the suppuration precedes, and 
does not follow, the polypoid hypertrophies. 

It has been an old and accepted view that the constant drain¬ 
age of a purulent secretion over a given area of nasal mucosa 
will sooner or later give rise to polyposis; therefore, these hyper¬ 
plastic structures are the result of secondary irritation due to the 
outflow of secretion. This statement was accepted in its literal 
sense, no modification being observed, and, indeed, some authorities 
even considered the mere presence of polyps in the nose as 
pathognomonic of sinus suppuration. While occasional dissent was 
made, 533 it was not until Uffenorde put himself on record by 
stating that the suppuration was more often secondary to the 
polyposis, 534 and endeavored to prove the same, that interest was 
given to this thought. He reasoned as follows: From repeated 
attacks of simple catarrh, numerous polyps made their appear¬ 
ance from the ethmoid region until a greater portion of the nasal 
chamber was occluded. Ventilation, as well as the possibility of 
cleansing by blowing, was so seriously interfered with that the con¬ 
tinually-forming secretion became stagnated between the polyps. 
Putrefaction followed and infection resulted, particularly during 
an attack of acute coryza. As the ostia of the sinuses are more 

530. Flath: Ein Fall von doppelseitiger Mucocele. Dissertation Giessen, 1902. 
531. Ballenger: Discussion to Various Infections of Ethmoid. Trans. Am. Acad. Ophthal. 
and Oto-laryngology, p. 126, 1909. 532. Casselberry, Freer, Ballenger: Pathology of 

Ethmoiditis, Sec. on Lary. Am. Med. Assn., p. 200, 1910 533. Sieur and Jacobs: Les 

Fosses Nasales et leurs Sinus, p. 268, 1901 (note). 534. Uftenorde (518), S. 64. 




ETHMOID LABYRINTH. 


345 


or less occluded, the infection spreads along their mucosa and 
results in its permanent involvement. This theory took its in¬ 
ception form the reports of Alexander 535 and Skrodski, 536 who 
found, on the section table, absolutely no relation between the 
occurrence of polypi and the existence of sinus empyema. 

Our views on this subject have already been advanced (see 
Relation of Polyps to Empyema), so that no further comment 
is necessary. It might, however, be added that we do not accept 
Uffenorde’s views in their entirety, but believe nasal polyps, under 
certain circumstances, result entirely from irritation of the 
purulent secretion exuded from diseased sinuses. 

Sluder 536a seems to consider that the purulent infection pre- 
ceeds the hyperplasia for he says “ as the inflammatory process 
continues the secretion loses all purulent character and. the hyper¬ 
plasia begins/’ If this is true I have frequently overlooked the 
purulent stage as in most of my cases this has been absent. 

Complications.— External Rupture with Fistula Formation .— 
This seems to be the most frequent form of any complication 
resulting from purulent sinus affections. This is not at all un¬ 
natural when we consider the anatomical configuration of these 
parts in which the orbital structures are separated from the 
ethmoid labyrinth by only the thinnest possible plate of bone 
(lamina papyracea) which frequently shows defects throughout 
its entire formation. 


The point of predilection for perforation to occur is in the region of the 
ethmo-lachrymal suture. In a large number of instances the lachrymal bone is the 
seat of numerous pin-point perforations, or if the process has well advanced, an 
entire melting down of this thin bony structure is observed. 


The frequency of abscess and fistula formation, and infre¬ 
quency of severe orbital affections, is in a very large measure due 
to the orbital periosteum of the lamina papyracea. The infection 
penetrates this bony plate and reaches the orbital periosteum. 
Here considerable resistance is encountered, which may result 
merely in a slight plastic form of periostitis, or, if the infection 


535 Alexander (111). 536. Skrodski: Zur Aetiology der Nebenhohlenempyem. In¬ 
tern Zentralblatt fiir Larvng., S. 332, 1897. 536a. Sluder: Headache and Eye Disorders of 

Nasal Origin p.137,1919. 536b. Myers (Quoted by). Blindness as a Symptom of Obscure 

Ethmoid Disease. Joum. Ophth. Otol. and Laryng., p. 127, April, 1921. 





346 


THE ACCESSORY SINUSES OF THE NOSE. 


is persistent, the new-forming purulent secretion, not being able 
to penetrate the periosteum, will burrow beneath in the line of 
least resistance, finally emerging at the superior internal angle of 
the eye. 

Ocular disturbance of vision from infections of the posterior 
cells occupies almost as prominent a position as that resulting 
from sphenoid involvement. It was formerly believed that in 
order to cause serious interference with the visionary functions, a 
purulent collection or collections within the ethmoid cells prefer¬ 
ably closed in and under pressure was necessary, therefore after a 
thorough examination if no sign of this was present the ethmoid 
cells were ruled out as a possible causative factor of the occular 
condition. Since the advent of the recognition of hyperplastic 
ethmoiditis, these older theories have been discarded for it has 
been definitely proven that this hyperplasia of the mucosa can be a 
forerunner of all sorts of disturbances of vision from a transitory 
shadow to complete and permanent blindness. The importance of 
this relationship can be judged when authorities 53521 state that these 
posterior cells are found to be the foci of infection in at least 40 per 
cent, of all cases of obscure blindness. The onset of the occular dis¬ 
turbance may be so insidious as to be lightly regarded by the 
patient as a slight cloudiness of vision and remain neglected until 
permanent pathological changes have resulted in the optic nerve. 
Experience shows more and more the longer the condition remains 
undisturbed, the less liklihood of improvement in vision after 
operation. In other words, the more the choking of the optic disc, 
the less the return of vision. (See p. 401 Retro-bulbar neuritis). 

Orbital: Acute and Chronic Rupture into the Bulbar Cavity .— 
Acutes Acute rupture into the orbit is characterized by sudden 
outward dislocation of bulb, swelling and infiltration of eyelids, 
intense pain in the eye which radiates over that side of the fore¬ 
head, high fever, and general prostration. Fluctuation may be 
felt above the inner canthus if the purulent mass be forward. 

The following case, seen in eonsulation with Dr. John A. Brophy, well illus¬ 
trates this condition: 

Henry A., 16 years old. History of previous nasal occlusion. Awoke on the 
morning of August 13, 1911, with right eye enormously swollen, exophthalmos, 
lids tightly closed with total blindness on affected side. Pulsating pain in parietal 





ETHMOID LABYRINTH. 


347 


and temporal regions on right. No pain in eye. Total occlusion of right nares. 
Temperature 102°. On August 17, operation. Usual curved incision. On exposing 
lachrymal bone it was found to be so necrosed that the tip of the little finger was 
easily passed through into the anterior ethmoidal labyrinth. The entire ethmoid 
capsule was found to be polypoid, degenerated and bathed in pus and was there¬ 
fore completely exenterated. Sphenoid sinus empty. Wound partially closed, 
drainage into nose and externally. Following day, temperature 100°. Pulse 100. 
Entirely free from, pain, but no change in appearance of eye (Fig. 206). August 
19, exophthalmos much reduced. Patient begins to distinguish light. August 30, 
patient discharged from hospital. 

Unless prompt measures are 
taken to evacuate the pus, it will 
quickly find its way backward 
along the sheath of the optic 
nerve and penetrate into the 
cranium, causing lethal intra¬ 
cranial complications. 

Chronic: Chronic rupture 

occurs in a totally different man¬ 
ner from the acute, having none 
of the stormy symptoms found in 
the former. It usually begins 
gradually, becomes larger with¬ 
out pain or any inflammatory 
symptoms. The eyeball is, little 
by little, dislocated in the usual 
direction. Chronic oedema of the 
lids make its appearance early 
in the process. Rupture may 
occur without symptoms, or, if 
an acute exacerbation has set in, 
with all the appearance of an acute process. 

Orbital abscess formation can occur without any perforation 
of the lamina papyracea through the ethmoidal veins. In such 
case there are two distinct foci of purulent material—one in the 
ethmoid cells, the other in the orbital tissues. It is often difficult 
to differentiate these conditions; however, two manipulations 
may be tried, which, if successful, will clear the diagnosis. By 
pressing on the swelling or by allowing the patient to hold the 
nostril and forcibly blow, as in the Valsalva method, pus may be 
made to exude into the nasal cavity. In the later instance the 
swelling will become larger, but returns to its original size as soon 



Fig. 206.—Marked exophthalmos due to rup¬ 
ture of an ethmoidal empyema through the lamina 
papyracea into the orbit. 


348 


THE ACCESSORY SINUSES OF THE NOSE. 


as the pressure is relieved. If the abscess has already ruptured, 
blood mixed with pus will be forced out. 

Inflammation of the Lachrymal Duct .—This affection is not 
rarely associated with purulent conditions in the anterior ethmoid 
cells, largely due to the arrangement of the circulation. The 
lachrymal sac is surrounded by a network of arteries, a number 
of which pierce the lachrymal bone, penetrating into the in¬ 
fundibular cells and those of the uncinate process. The returning 
veins can carry infection from the cells to the lachrymal sac, thus 
setting up inflammation. 537 

Functional disturbances are largely due to the hyperaemia and 
pressure from circulatory disturbances. As most of the eth¬ 
moidal veins empty into the ophthalmic, engorgement of these 
vessels causes a damming back of blood into the veins of the 
orbit, and particularly in the ciliary network, producing an ex¬ 
aggerated tension in the interior of the eye, which in turn causes 
disturbances in the circulation of the retina and a beneficial in¬ 
fluence upon the nervous tissues. 538 

Cerebral: Intracranial Complications .—These usually occur 
through the cribiform plate, either by direct extension or through 
the ethmoidal veins, which richly anastomose with those of the 
dura in this region. In the latter instance the bone may be 
absolutely intact. 

Meningitis : 539 Phlebitis of cavernous sinus and brain abscess 
appear to be the most common forms of intracranial infection 
following purulent ethmoiditis. The infection seems, for the most 
part, to have penetrated the lamina cribrosa. either through the 
natural channels or by caries and necrosis. In contradistinction 
to the frontal sinus, these meningeal complications occur more 
frequently with the acute than the chronic ethmoiditis. 

Cavernous sinus thrombosis results from the direct infection 
of the ethmoidal veins which empty into the ophthalmic and thence 
into the cavernous sinus. 

Prognosis.— Chronic purulent ethmoiditis always requires a 
certain degree of operative interference before a cure can be ob¬ 
tained. If the pus is limited to a few isolated cells, and these are 
freely opened, a speedy cure will always result. If the entire 

537. Antonelli: Sinusite ethmoido-frontale suite de cellulite orbitaire provoquee par 
une dacryocystide. Soc. d’ophthalmol. de Paris, Feb. 6, 1900. 538. Ziem: Apropos des 
Rapports des maladies du nez avec les maladies des yeux. Ann. des mal. de l’oreille, etc. 
p. 491, 1892. 539. Krauss: Two Cases of Acute Suppurative Ethmoiditis in Children, 
Resulting in Death. N. Y. Med. Journ., vol. 89, p. 839, 1909. 




ETHMOID LABYRINTH. 


349 


labyrinth is suppurating, we face a totally different proposition, 
as one or two cells are almost sure to escape any intranasal in- 
tervention. The presence of necrotic tissue very materially adds 
to the length of time required for complete resolution, and if 
extensive necrosis has occurred, subsequent healing may be in¬ 
definitely posponed, particularly if the process has invaded the 
cells of the fovea ethmoidalis. 

Certain authors lay stress upon the species of infecting micro¬ 
organism being in direct relation to the ultimate prognosis; 540 
thus, a pure staphylococcic infection may be considered good; 
streptococcic, pneumococcic, and that resulting from the bacillus 
of Friedlaender are unfavorable. An infection due to the pneu¬ 
mococcus exhibits a decided predisposition towards meningeal 
infection (some form of meningitis). 

After all has been said, the entire prognosis hangs upon the 
question of free drainage. If this has been installed it is good; 
otherwise it is bad in direct proportion to the number of foci of 
suppuration which have been left undisturbed by the operation. 

Conservative Treatment.— Presupposed that the frontal and 
maxillary sinuses have been excluded and that the ethmoid is 
purulently affected, the indications are to remove crusts and puru¬ 
lent secretion and at the same time place the nose in such a con¬ 
dition as to cause free drainage from the ostia of the affected cells. 

In ordinary cases, where no retention symptoms are present, 
this may be attempted by systematic lavage after the middle tur¬ 
binate has been refracted or partially removed as indicated. Any 
alkaline non-irritating liquid may be used. The patient should be 
instructed to syringe the nares morning and evening, care being 
taken not to forcibly blow the nose immediately afterwards on 
account of the danger of driving the fluid into the middle ear. 

If the case is not so cronic that ordinary drainage will suffice 
to bring about resolution, this form of treatment under regular 
rhinoscopic supervision will often bring about a complete cure. 
Should polyps and polypoid hypertrophies be present before in¬ 
stituting any form of treatment, either at the office or at home, 
it will be necessary to completely remove these hyperplasias, for 
the rationale of this treatment depends absolutely upon the instal¬ 
lation and continuance of free drainage. 

The length of time this treatment should be continued depends 
upon many contingencies. If all subjective symptoms are allevi- 

540. Sobernheim: Bakt, Untersuchung z. Prognos. u. Behandlungswahl, etc. Arch. f. 
Laryng., Bd. 23, S. 159, 1910. 




350 


THE ACCESSORY SINUSES OF THE NOSE. 


ated, only the annoyance from the discharge remaining, the choice 
of an operation or of continuing along the same lines lies entirely 
with the patient. If on the other hand, the disease recurs with 
increasing severity with each fresh attack of coryza, the indi¬ 
cations are as with the vermiform appendix, to remove the dis¬ 
eased structure. 

Treatment by Vaccination .—In old and persistent cases this method has 
been found of service, particularly when the cells are inoperable from an in intra¬ 
nasal standpoint. A culture is made from the discharge. After isolating the infect¬ 
ing germs a vaccine is made from sub-cultures of them. This is given hypoder- 
matically in increasing doses until a positive reaction occurs. A prompt subsidence 
of the secretion will follow in those cases wdiich respond favorably to this form 
of treatment. 



Intranasal Method .—This procedure may be termed the semi¬ 
radical method through the nose, as it consists in removing intra- 
nasally all cells which show signs of suppuration. It is indicated 
in all cases of uncomplicated suppurating ethmoditis which re¬ 
quire an operation. 

Method: (1) Cocainize with cocaine adrenalin as before. 

(2) Remove all polyps. 

(3) Remove anterior extremity of middle turbinate high up. 

It is important to control all hemorrhage before proceeding further, as an 
unobstructed view of the base of the ethmoid capsule is absolutely necessary, else 
it would be impossible to judge the extent of the suppuration. To accomplish this 
cotton mops saturated with adrenalin chloride and held firmly against the bleeding 
structures will generally in a few moments control the oozing. The naris on that 
side should be washed out. 

(4) The bulla is opened with Hajek’s hook (Fig. 207) by in¬ 
serting the point at the posterior portion and drawing sharply 
forward. (Fig. 208.) 













ETHMOID LABYRINTH. 


351 


This is easily accomplished, as the diseased bone gives way quite easily before 
the hook. By this manipulation the lowest cell of the ethmoid is opened so that 
drainage is at least insured at that particular locality. Little bleeding occurs at 
this point. 

(5) Enlarge opening by biting away walls of the cells together 
with the mucosa by means of the Griinwald forceps until all dis¬ 
eased structure has been removed. (Fig. 208a.) 

The operation may end at this point, or, if necessary, may be 
carried further by resecting the uncinate process, thus reaching 
the infundibular cells. Curetting is very dangerous, and should 
be applied, if at all, with the greatest caution. While using the 











Fig.^ 208.—Opening the ethmoidal bulla with 
Hajek’s hook after resection of the anterior portion 
of the middle turbinate. 



5 ^ 


Fig. 208a. — Removal of the bulla with the 
Griinwald conehotome after the anterior end 
of the middle turbinate has been removed. 


forceps it is well to remember that the lower edge of the middle 
turbinate is approximately the half-way line between the nasal 
floor and the lamina cribrosa. It must always be borne in mind 
that it is better to do too little than too much, for if a focus of 
suppuration is overlooked, it can be reached at a subsequent 
operation. Unless undoubted signs point to posterior cellular 
involvement the lamella of the middle turbinate should be our 
posterior boundary for the operation, and never broken through, 
as an infection of the cells of the superior nasal passage will result. 

After finishing the operation the nose is again flushed out with 
the warm saline solution, and bismuth-formic-iodide powder in¬ 
sufflated over the operated areas. A plug of cotton in the opening 
of the nares closes the procedure. 




352 


THE ACCESSORY SINUSES OF THE NOSE. 


Packing the nostril with gauze is distinctly contra-indicated in purulent con¬ 
ditions of the ethmoid. The danger of complications from damming back the pus 
far exceeds the benefits derived toward the prevention of post-operative hemorrhage. 
Asa matter of fact this bleeding is little to be feared. While a certain amount of 
oozing is sure to occur, coagulation will follow if the patient remains quiet and 
does not assume a reclining position. We have never been called upon to tampon 
the nose after this operation. 

The immediate result of the operation is a distinct increase 
in the amount of the discharge due to the free drainage estab¬ 
lished as well as to the postoperative irritation. This secretion 
usually diminishes little by little until it either ceases entirely or 
continues to a minimum degree. After healing is established (about 
two weeks) if the secretion continues profuse it is wise to gently 
syringe about 1 dram of a 3-5 per cent solution of silver nitrate 
directly into the wounded parts. This will often bring about a great 
amelioration in the amount and purulent character of the discharge. 

The ultimate results of this operation are good as regards 
alleviation of the distressing symptoms and uncertain as to the 
future course of the suppuration. Sometimes the discharge is 
entirely checked, other times it is continuous as before as far as 
the profuseness is concerned. The cause of continued secretion 
lies either in a diseased cell which has been overlooked, or, what 
is more frequently the case, in an infected cell which is situated 
beyond the reach of an endo-nasal procedure. Such cells are the 
fronto-orbital and orbital. The advantages of the operation, how¬ 
ever, far overshadow any discomforts attending the more or less 
constant discharge, for free drainage has been established, thus 
doing away with the subjective symptoms (headache, mental dis¬ 
turbances, etc.) as well as preventing as far as possible the occur¬ 
rence of cerebral and orbital complications. 541 

This operation will often, particularly in the acute stage, suffice when actual 
complications have occurred, and, indeed, Farlow 542 says he has found no cases where 
other than persistent intranasal treatment has been advisable. 

Certain cases where sufficient room exists between the middle 
turbinate and the septum or in which the middle turbinate is not too 
thick, it is often possible to open and drain the anterior ethmoid 
cells without sacrificing any portion of the middle turbinate itself. 
This is accomplished by, first, opening the cell in the agger nasi well 
in front of the anterior attachment of the middle turbinate either 
with a suitable curette or Griinwald forceps; then by going under 

541. Hajek: Akutes Empyem des Siebbeinlabyrinthes, etc. Zeitschr. f. Lary., S. 629, 
1909. 542. Farlow: The Ethmoid Sinus. Trans. Am. Laryn. Assn., p. 238, 1905. 





Fig. 209.—Mosher’s operation. A. 1st step. Curette in piace. B. 3d step. Middle turbinate borne 
through. C. 4th step. Curetting away processus uncinate. D. Ethmoid cells removed with curette under¬ 
neath middle turbinate. E. Middle turbinate being removed with scissors. F. Complete. 


23 


















































































































































































































































• - 









































ETHMOID LABYRINTH. 


353 


the middle turbinate and pushing it toward the septum to attack 
the bulla and open it up as widely as possible, thus giving aeration 
and drainage to these cavities. By continuing upward and forward 
the infundibular cells and eventually the frontal sinus can 


be reached. 5410 

Mosher’s Method of Complete Exenteration of the Ethmoid 
Capsule. 5 * 1 *' 541 " —Anaesthetize the middle turbinate and middle 
nasal passage with the 20 per cent, cocaine-adrenalin solution.* 

1. Introduce a long thin-beaked curette well up anteriorly 
between the middle turbinate and the septum, about one-third the 
distance posteriorly (Fig. 209, A). 

2. Press the beak of the instrument against the middle turbinate 
until it penetrates this structure and comes to rest in the hiatus 
semilunaris. 

3. The curette is now brought forward and downward, thus 
tearing through the anterior third of the middle turbinate and 
exposing the surrounding structures (Fig. 209, B). 

4. The cutting surface of the curette is now brought forward 
until the anterior lips of the hiatus semilunaris is encountered. A 
few strokes of the curette remove this structure, thus bringing the 
entire anterior ethmoidal labyrinth into view (Fig. 209, C). 

5. The ethmoid labyrinth is now removed from before backward 
with the curette, beginning at the bulla and ending at the anterior 
wall of the sphenoid (Fig. 209, D), keeping the remains of the 
middle turbinate as a landmark and guide. 

6. The remaining portion of the middle turbinate may now be 
removed with the scissor-punch, thus completing the operation 


(Fig. 209, E). 

Method of Luc 5 * 3 — Anaesthetize by packing three strips of gauze 
soaked in 20 per cent, cocaine-adrenalin solution in the following 
places: (1) in middle nasal fossa between middle turbinate and 
lateral wall of nose; (2) between middle turbinate and septum as 
high as possible; (3) along the free edge of the middle turbinate. 
Allow these to remain in place fifteen minutes, after which time the 
parts will be thoroughly ischaamic and insensible to the touch._ 


La! ^ I *In complete removafof thee'thmoid^labvrmth Mosher now prefers a general an*s- 
thetic .—Personal Communication. 





354 


THE ACCESSORY SINUSES OF THE NOSE. 


(1) Seize the anterior end of the middle turbinate, using the 
author’s forceps (Fig. 210), and by a twisting motion tear as 
large a portion as possible loose from its attachments. Repeat this 
maneuver until all of the structure is removed. 

(2) The bulla now being exposed is grasped in like manner and 
torn out from its attachment. 

(3) The remaining ethmoid cells are removed piecemeal with¬ 
out regard for the lamella until the entire ethmoidal capsule is 
exenterated to the anterior wall of the sphenoid. 

After the nose is washed free of the fragments, tampons sat¬ 



urated with peroxide of hydrogen are applied for several minutes. 
He warns against the application of permanent tampons. 

Sluder’s Method . 542a —Anaesthetize in the usual manner. 

1. The ethmoid knife is introduced under the anterior third of 
the middle turbinate as far back as the uncinate process and as high 
as the cribriform plate, cutting edges facing forward. The blade is 
rotated inward and drawn forward and downward. (Fig. 210a) 

2. The knife is now introduced between the middle turbinate and 
septum until its smooth elbow is in contact with the cribriform plate 
about half way back to anterior sphenoidal wall, the cutting edges 
facing downward. The blade is rotated until its cutting edges 
point outward and slightly upward (Fig. 2105) and again drawn 
forward and downward. 

3. Remove the portion of the middle turbinate left hanging by 
the incisions with a snare. (Fig. 211c.) 

4. The ethmoid cells can now be broken down with the knife- 
hook and debris removed with the Knight forceps. (Fig. 211d.) 

542a. Sluder: A Surgical Consideration of the Upper Paranasal Cells. Ann. of Otol. 
Rhin. and Laryng., June, 1917. 







Fig. 210.—Seizing and twisting the middle turbinate 
from its anterior attachment. 


Fig. 211. —The hook behind the posterior por¬ 
tion of the middle turbinate in position for sever¬ 
ing the turbinate from its attachment. 




Fig. 212.—The ethmoid hook in position for reduc¬ 
ing the superior turbinate to fragments. 


Fig. 213.—Finishing the stroke with the hook in com¬ 
plete exenteration of the ethmoid capsule. 





















































































































































































ETHMOID LABYRINTH. 


355 


This method has a decided advantage where the nasal septum 
is markedly deviated toward the affected side as the knives required 
are exceedingly slender, requiring little room to obstruct the vision. 
If the snare cannot well be introduced, the resection of the middle 
turbinate can be completed with the knife. 

Hajek’s Method for Removing Posterior Ethmoid Cells. —(1) 
Anaesthetize in usual manner. 

(2) Pass hook behind attachment of middle turbinate and cut 
forward, thereby severing it completely from its attachment. 
(Fig. 211.) The posterior end is then seized with the forceps and 
drawn forward in order to remove as much as possible at one 
attempt, thus exposing the superior turbinate. 

(3) Pass hook backward point downward until it reaches the 
highest point attainable on the anterior sphenoidal wall (Fig. 212), 



Fig. 211c. —Sluder’s method, removing turbinate Fig. 211d.—Sluder’s method, removing debris 
with snare. with forceps. 


then turn point outward, burying it as deeply as possible into the 
superior turbinate. 

No fear need be entertained regarding injury to the orbital plate, as the length 
of the hook is not so great as the depth of the ethmoid capsule at this point. 

(4) Freely open cells by withdrawing hook forcibly toward the 
nasal outlet, and repeat procedure until that part of the capsule 
is reduced to shreds. (Fig. 213.) 

(5) Remove fragments with suitable forceps (Luc or Griin- 
wald), and see that no recesses or partitions remain. (Fig. 214.) 

(6) After thoroughly washing, powder thoroughly with bismuth- 
formic-iodide powder. 

Slight Complications Sometimes Following Intranasal Opera - 
tion. —Hyperaemia of conjunctiva. This is a not infrequent sequela. 
The discoloration is often intense, being due to the traumatic 
stagnation in the ethmoidal veins leading to that portion of the 



356 


THE ACCESSORY SINUSES OF THE NOSE. 



eye. No fear need be felt for the outcome, as wet compresses of 
hamamelis virginiana will always reduce the hyperaemia and swell- 
ing in a few hours. 

Emphysema of the Upper Eyelids on Blowing the Nose .—When 
this condition makes its appearance we can be sure that 
either a dehiscence exists in the orbital plate or we have broken 
through with our instrument. It is characterized by a sudden 
swelling of the lid, accompanied by a sharp, lancinating pain. On 
examination distinct crepitus may be felt. In treating this condi¬ 
tion we must, as far as possible, 
guard against purulent infec¬ 
tion of the orbital structures. 
For this purpose absolute rest 
at home with cold compresses of 
equal parts of euthymol and 
water will cause the emphysema 
to disappear in the course of sev¬ 
eral days without the develop¬ 
ment of further complications. 

EXTERNAL OPERATION 

If, despite every intranasal 
effort the suppuration and gen¬ 
eral symptoms continue, an ex- 
ternal operation is indicated. 544 
Threatened rupture, abscess and fistula formation, beginning 
cerebral complications also call for external interference. 


If perforation has already occurred before operating, it is wise to introduce the 
sound into the fistula and endeavor to ascertain whether the perforation extends 
through the orbital place and, if present, the size and situation of the opening. 

Fatalities following the intra-nasal method have occasionally 
been reported. 543 * 1 I have seen but one case under my own observa¬ 
tion which terminated fatally after an exenteration of the ethmoid 
with the Luc’s forceps under ether. In this instance, the patient 
was discharged from the hospital, apparently in good condition, on 
the second day and on the fourth day returned to the office in a semi- 
dazed condition. He was sent back to the hospital and in forty- 
eight hours was dead from acute meningitis. 


543a. Ostrom: Ethmoid Operations During the Latent State Followed by Death. Re¬ 
port of Cases. Annals of Oto., Rhino, and Larvng., p. 556, June, 1921. 544. Coffin: Ex¬ 

ternal Operation for Relief of Ethmoiditis. Ann. Otol., Rhin. and Laryn., p. 491, 1905. 



ETHMOID SINUS. 


357 


Technic: Under general narcosis a curved incision is made 
from the eyebrow to a point about one-third of an inch below the 
inner canthus of the eye. The incision is continued down to the 
bone. The periosteum and soft parts are elevated, pushing aside 
the trochlea until the lachrymal fossa is reached. The lachrymal 
sac is pushed out of its bed and the entrance to the anterior ethmoid 
labyrinth lies before us. 

A hollow chisel is used to open the cells, removing a portion of 
the frontal process of the superior maxillary if found necessary to 
gain room. The cells are removed, piece by piece, with the Griinwald 
or similar forceps until the damella of the middle turbinate is 



Fig. 215.—Position and length of incision for Fig. 216.—Periosteum retracted and bone bared, 

external radical exenteration of the anterior and bringing out the various felations, including the 
posterior ethmoid cells. landmark (lachrymal groove). 


reached Orbital and even frontal cells can easily be followed up to 
their endings. After all the diseased parts have been removed a 
large counter-opening is made through the bulla into the nose, and 
the external wound permanently closed. 

If for any reason drainage is deemed necessary a wick of iodo¬ 
form gauze is inserted into the depths of the cavity and the external 
wound closed only at its extremities. If the symptoms of the 
threatening meningeal complications disappear, the gauze is 
removed after three days and the incision allowed to heal. 

Method of Guisez. 545 — (1) Eyebrow shaved and region thor¬ 
oughly disinfected, nose lavaged with hydrogen peroxide. 

(2) Under general narcosis an incision through the inner fourth 
of the eyebrow is made, descending towards the inner angle of the 

545. Guisez: Du Traitement chlrurgical de Fethmoidite purulente. Ann. des Mai. de 
l’orielle, etc. Abotit, p. 116, 1902. 



358 


THE ACCESSORY SINUSES OF THE NOSE. 


eye, but passing around it several millimetres below the lachrymal 
fossa. (Fig. 215.) 

At the internal and terminal portions the incision will penetrate to the bone, 
but in the middle, in the region of the caruncula, it must be superficial to allow very 
delicate dissection. 


Bleeding will be free at this point and must be controlled by 
haemostats before proceeding further. The supra-orbital nerve 
must also be entirely severed, so as not to become bound up with 
the cicatrix. 


(3) Dissect carefully layer by layer, cutting successively the 
tendons of the orbicularis and muscle of Horner, until the lachry- 



Fig. 217.—Point of election for opening the 
ethmoid labyrinth. _ The ridge between the lachrymal 
groove and the lamina papyracea. 


Fig. 218. —The operation completed. All of the 
ethmoid cells have been removed to the anterior 
sphenoidal wall. The sphenoidal ostium is visible 
in the depths of the wound. 


mal sac is seen in the depths of the incision. This structure is 


now carefully lifted out of the fossa and pushed as far as possible 
to one side, in order to avoid wounding it during the later stages 
of the operation. (Fig. 216.) 


During this stage of the operation one must avoid injuring the anterior 
ethmoidal artery, as hemmorhage from this source is not only difficult to arrest, but 
also entirely masks the field of operation. 

(4) Denude the surface of the lachrymal bone and os planum 
from the periosteum as far as possible. The occular globe with 
the capsule of Tenon is entirely separated from the internal 
orbital surface, avoiding the tendon of the superior oblique. 
(Fig. 216.) 

(5) The internal wall of the orbit being bared, one of two con¬ 
ditions may be present: (a) the bone may be intact, or (b) a 
spontaneous rupture may have taken place. 



ETHMOID SINUS. 


859 


(a) If the bone is intact, make a small opening with the chisel 
behind the lachrymal suture. (Fig. 217.) Enlarge this orifice 
with the forceps and curette, resecting completely the lachrymal 
bone as well as a portion of the frontal process of the superior 
maxilla. This is necessary in order to lay bare the lachrymal- 
ethmoidal cells. Posteriorly the orbit is separated from the os 
planum with a blunt retractor, or, better, with the index-finger, 
thus avoiding injury to the opthalmic artery and optic nerve. 
The superior boundary of the operation will be the fronto- 
etlimoidal suture. The entire opening in the os planum should 
measure about 2.5 cm. in height by 4 cm. in depth (anteroposte- 
riorlv). (Fig.218.) 

(b) If spontaneous rupture has already occurred, the sound 
should be used to ascertain the direction of the perforation, after 
which the bone will be resected in the direction of the fistula. 

(6) The ethmoid cells are now curetted with the greatest care, 
never using undue force, avoiding particularly the region of the 
olfactory fissure. The ethmoid labyrinth can thus be completely 
exenterated to the anterior wall of the sphenoid. 

This step of the operation must be quickly accomplished, as the hemorrhage 
will be rather profuse. To control this, sterile gauze is saturated with adrenalin 
chloride and packed in and allowed to remain for a few minutes. After gauze 
has been quickly removed, by means of reflected light it is possible to inspect and 
remove any fragments of bone and mucosa which remain in the depths of 
the wound. 

(7) After complete exenteration of the cells has been made, 
shall the subsequent approach be orbital or intranasal? If pus 
is present in the nasal fossa the treatment should be both orbital 
and nasal. All fungosities and polyps must be removed, the 
middle turbinate resected and a large counter opening made into 
the nose. The cavity is lightly tamponed through the orbital 
wound with iodoform or sterile gauze, one end of which is brought 
out through the nose. The nasal fossa is tamponed by a separate 
strip. The orbital wound is sutured except at the inferior ex¬ 
tremity where a small drain is allowed to remain for 24 to 48 hours. 
One thus avoids retention of blood which would favor infection or 
the production of a haBmatoma. After-treatment: The tampon is 
removed on the third day, after which daily cleansing of the nasal 
fossa is made by means of tampons saturated with hydrogen 
peroxide. Crusts, debris from the cells and portions of mucosa 
which have escaped the orbital operation are removed as they 


360 


THE ACCESSORY SINUSES OF THE NOSE. 


appear. A mild discharge often persists for several weeks, but 
is easily controlled by the antiseptic treatments and applications 
of tincture of iodine. The mucosa of the remaining cells resumes 
little by little its normal aspect. At the end of several weeks of 
patient and regular treatment a cure is obtained. Even in those 
cases in which no communication with the nose is present it is 
well to install one, as the better drainage thus procured will 
facilitate recovery much more quickly than when it is attempted 
solely through the orbital wound. 

Untoward Symptoms Following the External Operation. —Per¬ 
sistent ophthalmic changes. Chemosis of the conjuctiva, oedema 
of lids, restricted motion of the eyeball. Even if these conditions 
are of recent occurrence, they are apt to remain more or less perma¬ 
nent after the external operation, therefore one should be ex¬ 
tremely guarded in the prognosis as to the immediate resumption 
of the tissues to their normal appearance. 

Blindness .—Complete loss of sight on the affected side following 
operation has been reported by Smith. 545a 

545a. H. Smith: Blindness Incidental to External Ethmoidal Operation. Larvneo- 
cope, p. 216, 1915. 




DIAGNOSTIC INDICATIONS 

A patient, usually of importance, has been under our care for 
some time with a profuse chronic unilateral muco-purulent dis¬ 
charge, for the most part post-nasal, particularly annoying in the 
morning, chiefly on account of the glue-like secretion which accumu¬ 
lates in the throat and naso-pharynx. After weeks of treatment 
and having convinced ourselves that the frontal, maxillary and 
sphenoid are not diseased, we suggest opening and curettage of the 
ethmoid cells. We are surprised how small the quantity of purulent 
secretion is evacuated, as well as how apparently healthy mucosa, 
or at least but slightly affected, is removed during the operation. 
It occurs to us that the macroscopic pathology of the removed frag¬ 
ments did not justify the assumption that they were solely the cause 
of the troublesome discharge which had proved of such annoyance 
to our patient. Following along this train of thought, the sugges¬ 
tion and even the apprehension arises that we have not been as 
thorough in our exenteration as we might have been and indeed, as 
subsequent events prove, as was necessary for the eradication of 
the infection. However, we are quite optimistic and feel that after 
all with the cells opened by regular applications of argvrol or 
similar pigments, at least a great amelioration of the symptoms will 
be brought about. After many more weeks of treatment, the fact 
gradually forces itself home that the condition of the patient is 
unimproved despite our careful and painstaking surgery. 

It will be of little avail to state that we should not have operated 
in the first place, at least, in the method that was followed. Indis¬ 
criminate removal of alf the ethmoid cells within reach of our for¬ 
ceps was as unnecessary as it was unscientific. Here it was that 
we departed from the old maxim in sinus affections, “ Find the pus 
and follow it to its source.’ ’ We used our best judgment and by a 
g^Yggping operation hoped to include all the infected parts within 
the scope of our surgical procedure. From the very first, however, 
■^T 0 we re practically certain to fail on account of the almost insui- 
mountable obstacles which are for the most part present in sup¬ 
purative ethmoiditis. In the vast majority of cases, it is difficult 
and often impossible to adequately open all ethmoid cells by intra- 

361 


362 


THE ACCESSORY SINUSES OF THE NOSE. 


nasal methods. The cells which are most severely infected are 
usually those lying in the most inaccessible places, as for example, 
a supra-orbital cell in the anterior group or a deep-lying supra- 
maxillary cell in the posterior group. These can be and, as a matter 
of fact, usually are left undisturbed after even a complete intra¬ 
nasal exenteration where they remain to reinfect the remnants of 
the previously healthy cells which have been reduced to a dis¬ 
organized mass by our forceps and curette. In the ordinary run of 
these cases where the discharge was the predominating symptom, 
we should have systematically studied the conditions with all the 
means at our disposal. This can properly be preceded by complete 
removal of the middle turbinate followed by a satisfactory stereo¬ 
scopic X-ray. Careful and persistent study of these negatives will 
disclose the anatomic formation of the cells, even if they fail to 
show the diseased area which, in my experience, they seldom do in 
a convincing manner. The so-called extra capsular cells (fronto- 
ethmoidal, orbito-ethmoidal and maxillo-ethmoidal) are plainly 
seen in both shape and extent. This knowledge is of inestimable 
value in making subsequent deductions as to the probable origin of 
the pathological secretion and will very materially influence and 
limit the extent of the surgical interference. How much more satis¬ 
factory it is to have as a definite object the opening and draining 
of one or two large suspicious cells than to indiscriminately clean 
out the whole ethmoid in the hope of removing the diseased with 
the healthy structures. 

The exact method to be followed will, of course, vary with each 
individual case and is dependent upon following the pus to its 
source which may be long and tedious, but if carried to a success¬ 
ful termination will more than repay one by the conservation of 
tissue and prevention of the chronic state, not to mention the 
satisfaction evolved. 

To revert then to our patient, we will presume that conservative 
means have been applied for a sufficient length of time with little 
or no influence upon the course of the disease. The suppuration 
continues with but slight abatement and it becomes apparent that 
it can only be greatly influenced by some form of surgical inter¬ 
vention. What shall this consist off To open the lid of the eth¬ 
moid by removing the middle turbinate or by assuming the entire 
labyrinth should be removed and proceeding according to the 
method of Mosherf Obviously the latter is preferable if we are 


ETHMOID LABYRINTH. 


363 


convinced that a complete exenteration is indicated, but in our case 
we are by no means certain that the infection is not localized to a 
few cells where it will be possible to bring about a cure and at the 
same time conserve a large portion of the ethmoidal structures. 
Under these circumstances, the removal of the middle turbinate 
is unquestionably to be preferred, but it is right at this point, we 
are most apt to disregard our patience and continue the operation 
by removing those cells which he convenient to our forceps. This 
has proven, in my hands at least, to be an irretrievable blunder. 
Had our better judgment been followed, we would have contented 
ourselves with the turbinectomy and, after healing has occurred, 
continued with the further study of the case. In this way not only 
would the patient have had the benefit of the doubt as to whether 
resolution of the parts would have set in due to the resultant aera¬ 
tion and drainage incident to the removal of the turbinate, but the 
operator would have been in a far better position to follow up and 
judge the origin of the purulent secretion. In this way the offend¬ 
ing cells can usually be detected and by constant and persistent 
attention to these, the infection is finally eradicated. 

Suppose, however, we have followed our first inclinations and 
•after removal of the turbinate, attacked with forceps and curette, 
all cells within reach not neglecting to open the sphenoid. What is 
the result? Either we have, among other things, reached the dis¬ 
eased parts and removed them sufficiently to bring about a cure, 
or the patient returns in a few weeks with the most intractable 
case of suppuration ethmoiditis we have ever had on our hands. 
The symptoms of particular discomfort consist in the morning 
accumulation of glue-like masses in the naso-pharynx and constant 
nasal and post-nasal discharge. On examination, the ethmoidal 
region appears to be bathed in pus which does not seem to take its 
origin from any particular locality but fairly exudes from the whole 
of our former operative field. Removing this secretion, as careful 
as we will, either by cotton mop or lavage fails to disclose its precise 
origin and no form of conservative treatment from the application 
of aseptic irrigations, followed by medicaments to suction seems to 
have more than the slightest temporary influence upon its course. 
Now let us consider the precise pathological condition that con¬ 
fronts us We have indiscriminately removed all ethmoid cells 
within reach, to be sure to the best of our ability but, nevertheless, 


364 


THE ACCESSORY SINUSES OF THE NOSE. 


unavoidably left portion of those originally affected, with the result 
that instead of the infection being eradicated it gradually spread 
through the broken down and macerated structures until the whole 
mass was involved. This presents a very different problem from 
that which originally confronted us, particularly when one con¬ 
siders the pathological changes that have been wrought. The 
primary condition was one of purulent infection of one or more, 
possibly a group of cells, the mucosa of which was thickened and 
inflamed, but the osseous structures were unchanged both as to 
form and position. In other words, the labyrinth was intact. Now 
in its place we are dealing with a disorganized and suppurating 
mass, the landmarks having been more or less obliterated. The 
bone has attempted to regenerate with the formation of prolifera¬ 
tions of new osseous tissue through the trabecular of the cell rem¬ 
nants as well as the basic structures (lamina papyracea). Fibrous 
connective tissue has replaced the exuberant granulations which 
had succeeded the torn and traumatized mucosa with the result that 
now a semi-dense, suppurating, disorganized mass occupies the 
position of the operative area. Further operative procedures are 
soon found to be worse than useless owing to the fibrous character 
of the attacked tissues making the removal difficult, and on account 
of the force required, even dangerous. Given, however, that in an 
exceptionally favorable case, a large portion of this mass was re¬ 
moved, in but a comparatively short time, reinfection from the 
original focus would occur with a return to the old condition. 

Let us consider one of these operated cases has presented him¬ 
self for treatment. Examination has elicited the facts and condi¬ 
tions enumerated above. What shall be our line of procedure? 
Experience has taught us that further haphazard removal of tissue 
will avail nothing nor can conservative measures be continued in¬ 
definitely. We must revert to the old maxim. Find the pus and 
follow it to its source, but if it was difficult to apply this before, now 
it has become almost impossible; nevertheless, this must be at¬ 
tempted in order to scientifically and accurately bring the case to 
a satisfactory conclusion. When one examines the affected region 
even after thorough irrigation, the task appears thoroughly hope¬ 
less, purulent secretion everywhere but apparently coming from 
nowhere. Even the most painstaking probing fails to find a reser¬ 
voir, although irrigation into any cavity or recess never fails to 
bring forth traces of pus. In order to ascertain the source of the 


ETHMOID LABYRINTH. 


365 


discharge, we must begin the systematic study of the case by ex¬ 
cluding both the sphenoid sinus and maxillary antrum which almost 
invariably have become infected during the course of the disease. 
Needle puncture will bring forth the contents of the antrum, while 
the cotton-tipped applicator introduced into the opening of the 
sphenoid will disclose the nature of its contained secretion. Let us 
suppose that both of these cavities contained an appreciable amount 
of pus, the question instantly arises in our minds, how much of this 
is responsible for the amount which accumulates daily in the nose 
and naso-pharynx of the patient? To obtain this information, it is 
necessary that these sources be excluded. Several methods have 
been advanced to accomplish this purpose but I have found the most 
satisfactory to consist of the introduction of a small quantity of 
powdered methylene blue on a cotton pledget into the sphenoid after 
thorough cleansing and drying. Into the maxillary sinus it can be 
insufflated through a Lichtwitz needle. The patient is instructed 
not to blow the nose or clear the throat as far as possible until the 
next morning, then use a large cloth or towel. Comparison of the 
masses of blown or hawked-out secretion mil at once show the 
amount that is tinged with blue and that which is clear of coloring 
matter, thus giving one reliable data from which to draw a con¬ 
clusion. For corroborative purposes, this can be repeated until no 
further doubts exist. If it is shown that the mucosa of the sphenoid 
or maxillary is secreting a considerable amount, a differential diag¬ 
noses between these two can be made by alternating the application 
of the methylene blue between them. 

Let us presume we have disclosed that both these cavities con¬ 
tribute sensibly to the whole amount of secretion, our first endeavor 
is to eliminate these from further participation in its production. 
This can be accomplished in the case of the sphenoid by removing 
the entire anterior wall particularly toward the floor and the appli¬ 
cation of nitrate of silver solution in suitable strength (gr. xxx-Lx 
to oz.). In the case of the antrum, other measures may be neces¬ 
sary, such as a large opening below the inferior turbinate. Only 
after the discharge from these has been controlled should the eth¬ 
moid be attacked, but it should be remembered that the antrum 
can and often does act as a receptacle for the secretion exuded 
from the ethmoid. The proposition that now confronts us is to 
determine what portion of the ethmoid mass is responsible for the 
discharge. This is beset with so many difficulties as to make it 


366 


THE ACCESSORY SINUSES OF THE NOSE. 


ofttimes impossible, but should be attempted before ultra-radical 
measures are resorted to. The differentiation can proceed by con¬ 
sidering the anatomical division into the anterior and posterior 
group of cells and endeavoring to ascertain whether either of these 
groups or both are exuding the pathological secretion. At this 
point, it is well to recall that the anterior cells are small and shallow, 
while the posterior are large and deep; therefore, the chances 
are overwhelmingly in favor of the latter being at fault, particularly 
if the presence of a fronto-orbital cell is excluded which can be done 
by study of the stereoptical plates. If repeated inspection and the 
use of the probe shows that one of the constant sources of the secre¬ 
tion lies in the region of the uncinate process, it can pretty well be 
taken for granted that the secreting area lies in the immediate 
proximity. If, on the other hand, the discharge is for the most part 
post-nasal and irrigation over the spheno-ethmoidal region in¬ 
variably produces shreds and irregular globules of pus, it can 
hardly be controverted if one states that the infecting source lies in 
the posterior cells. When both these symptoms are present, which 
more often is the rule in these cases, the entire mass is usually 
involved. Suppuration in the anterior cells demands the removal 
of the uncinate process in order to uncover those situated along the 
infundibulum as well as in the agger nasi, but it has been my ex¬ 
perience that this alone is of little avail, as that portion of the 
ethmoid lying posterior to the lamella of the middle turbinate is 
always co-effected and requires resection before the infecting 
process can be brought to a halt. By reason of the operative space 
thus gained by removal of the uncinate process, the lamella of the 
middle turbinate can be broken through and the remnants of the 
posterior cells reached with much greater facility and thorough¬ 
ness than was previously possible. One is often enabled to make 
a complete exenteration to the orbital plate and into the spheno¬ 
ethmoidal fissure. The basic remains of the bony partitions can 
be fairly well smoothed off by sand-papering with compact wads of 
cotton held in the jaws of the nasal forceps. After treatment should 
consist of daily irrigations with a suitable solution such as hyper¬ 
chlorite of sodium. Excessive granulations may be touched with a 
strong solution of silver nitrate. Even should it be determined 
that the posterior cells are solely involved, this method will give 


ETHMOID LABYRINTH. 


367 


better results than attempting to remove them over the remains 
of the middle turbinate lamella, as a much wider field is present 
after the uncinate process is resected and there is less likelihood of 
overlooking pockets of infected mucosa. If this fails, I know of 
nothing that remains except the external operation. 

Guisez’s method or the external operation through the orbital 
plate is rarely indicated in these cases simply because the patient 
will not permit it, his symptoms not being of the severity to warrant 
such a radical procedure. At the most, he has a post-nasal dis¬ 
charge which is particularly irritating on arising, but after being 
cleaned out, he is fairly comfortable during the day. Headaches are 
usually not particularly disturbing and retention symptoms rarely 
present, as the cells have for the most part been widely opened and 
their points of least resistance are toward the nasal cavity. 

On the other hand, absolute indications for the external opera¬ 
tion occur after intra-nasal methods have been tried when 
certain eventualities prevail such as (1) the pressuse of a large 
infected fronto-ethmoidal cell which cannot adequately be opened 
and drained intra-nasally; (2) the occurrence of frequent and 
severe headaches traceable to the infection despite treatment; 
(3) progressively increasing septic condition of the patient; (4) 
external fistula formation; (5) threatened or actual orbital or 
cerebral complications. 

ULTIMATE RESULTS FROM OPERATIVE PROCEDURES. 

In the uncomplicated case of purulent ethmoiditis without polyp 
formation after the removal of the middle turbinate, the results 
obtained are usually inversely to the extent of the surgical disturb¬ 
ance; in other words, the greater the operative interference the 
less likelihood of return to normal and ultimate cure. Experience 
shows that once the middle turbinate is disposed of, the ethmoid 
labyrinth lends itself to conservative treatment and responds corre¬ 
spondingly with much greater facility than heretofore. In addition 
to this, the relations having been undisturbed, the ethmoid capsule 
and cells remain uninjured and intact. After a week or ten days, 
in how much more favorable a position are we to study and treat 
the pathological process, not to mention the benefit derived from 
the aeration and drainage effected by the turbinectomv. The infec- 


368 


THE ACCESSORY SINUSES OF THE NOSE. 


tion will have a tendency to limit itself to one or a small group of 
cells which only the most careful and ersistent study will disclose. 
This being finally accomplished it is a comparatively easy matter 
to install a large opening in their most dependent parts with a suit¬ 
able hook thus permitting aeration and drainage which coupled with 
irrigation, soon eliminates the active infection and puts the parts 
on the road towards resolution. In this instance the actual surgical 
interference has been small; therefore, the function of the nose will 
he unimpaired and the cure may be termed physiological, as well as 
therapeutic, leaving nothing to be desired. 

Unfortunately, this termination has been rarely observed owing 
to the fact that we have not followed a rational and systematic line 
of procedure. Our errors were either of omission or commission, 
we did not operate at all or having decided to operate, were not 
satisfied with a simple middle turbinectomy, but continued by re¬ 
moving certain of the ethmoid cells. The results of this are, of 
course, a continuation of the suppurative process, together with a 
disorganization of the ethmoid structures which makes a compre¬ 
hensive study almost impossible. We can therefore state that the 
ultimate results of this form of operation are to all intents and 
purposes disappointing and unsatisfactory. 

The next step is the complete intra-nasal exenteration, after 
removal of the uncinate process. This, in my hands, except in 
isolated instances, has been disappointing for the reason that it 
has been applied only as a semi-final resort when the pathological 
process has invaded the basic structures to such an extent that any 
intra-nasal procedure has been practically hopeless from the first. 
In those cases where the anatomical configuration lent itself easily 
to intra-nasal measures, the ultimate results have been crowned 
with success, but the cures have never been so striking as in the first 
instance, as the patient was subject to more or less permanent dis¬ 
charge, particularly on the inception of every fresh cold in the head. 

As far as the external radical operation is concerned, my experi¬ 
ence has been limited to a dozen or more cases. The patients 
are always relieved, but are never physiologically cured. The 
operated side of the nose remains a locus minor resistentia, always 
prone to more or less infecting disturbances, with the usual ac¬ 
companying symptoms. 


PART V. 

Sphenoid Sinus. 

Anatomy. 

The sphenoid sinus occupies the body of the sphenoid hone, 
being situated directly behind the ethmoid capsule at the posterior 
and superior portion of the nasal cavities. (Fig. 13.) In the fully 
developed stage it represents a cavity which may be regular, irregu¬ 
lar, large or small, depending upon the amount of reabsorption of 
spongy bone which has occurred. If the sinus is small, the walls are 
correspondingly thick. In very large sinuses the walls may be of 
paper thinness, which at once explains the relatively greater orbital 
and cranial compli¬ 
cations occurring 
in larger sinuses. 

Complete absence 
of both sphenoid si¬ 
nuses is not uncom¬ 
mon (Fig. 193). 

When this occurs 
a small dimple is 
always present on 
the anterior wall 
corresponding t o 
the position of the 

ostium. The aver- (v® 

age capacity of the 

. , . Fig. 219.—Sphenoid bone and ethmoid capsule disarticulated. 

sphenoid sinus 

from 180 specimens taken at random may be placed at 5-6 cm. 546 

If we take a disarticulated specimen and view it from the 
anterior aspect, it will be noted that the anterior walls of both 
sinuses seem to be entirely lacking. (Fig. 219.) These are com¬ 
pleted by the articulation of the ethmoid capsule (Fig. 220), the 
apposition of which entirely closes the opening except for a 
small aperture towards the median line, the ostium sphenoidale. 
The sinuses are separated from one another by a partition 
(septum), which, like that of the frontal sinus, may be considered 
as a continuation of the nasal septum. Along the anterior 



546. Sieur and Jacobs (506), p. 290. 


369 



370 


THE ACCESSORY SINUSES OF THE NOSE. 


attachment this septum is usually in the median line, but as it 
extends backward it frequently deviates to one side, thus making 
one sinus much larger than its fellow (Fig. 221). Complete absence 
of this partition, throwing both sinuses into one large cavity with a 
single ostium, has also been observed. 



Fig. 220.—Sphenoid bone and ethmoid capsule in position. 


The normal sphenoid sinus may be compared to a cube with 
six sides (walls): (1) the anterior or naso-ethmoidalis; (2) pos¬ 
terior or basilar; (3) superior or cerebro-pituitary; (4) inferior 
or choanal; (5) external or cavernous; (6) internal or septal. 



1. The anterior wall is the most important rhinologically, 
because it contains the ostium and is the point of attack in opera¬ 
tions on the sinus. It does not assume a true perpendicular posi¬ 
tion, but points backward and downward, thus forming an obtuse 






SPHENOID SINUS. 


371 


angle at its junction with the cribriform plate (Fig. 222), and 
gradually becomes thinner and thinner as it nears this articula¬ 
tion. As the ethmoid enters largely into the formation of this 
structure, it is divided into two portions: ethmoid (pars eth- 
moidalis) and nasal (pars nasalis). The proportion of these two 
pai ts depends largely upon the depth of the recess separating the 
internal portion of the posterior ethmoidal wall from the internal 
portion of the anterior wall of sphenoid. This groove is known 
as the recessus spheno-ethmoidalis (Fig. 176). It will thus be 
noted that the deeper this recess the larger becomes the pars 



Superior 

turbinate 


Middle turbinate 


Fig. 


222. Sphenoid sinus enlarged anteriorly, encroaching upon the space occupied normally 
posterior ethmoidal labyrinth. 


by the 


nasalis of the anterior sphenoidal wall and vice versa. The aver¬ 
age depth of this structure may be placed at 3-1 mm. 

The ostium of the sinus is situated in the nasal portion of the 
wall, usually in the upper third and seldom below the median line 
(Fig. 223). Whether it lies close to the nasal septum appears to 
depend largely upon the depth of the spheno-ethmoidal recess, as 
the deeper the recess the further away from the median line it 
seems to find its location. This is of great importance to bear in 
mind when attempting to pass the sound into this sinus. The 
position of the ostium in relation to the sinus floor is similar to 
that found with the maxillary, i.e., in a very unfavorable posi¬ 
tion for drainage. Its shape is oval in the long axis or round, 




372 


THE ACCESSORY SINUSES OF THE NOSE. 

and measures approximately 1—3 mm. in diameter. 04 ‘ The size of 
the opening in the recent state is usually smaller than in the bone 
itself, for the mucosa of the nasal cavity and sinus meet and form 



Fig. 223.—Section behind the uncinate processes, showing superior turbinates and position of sphenoid 
ostiums. (After Sieur and Jacobs.) 

a partial diaphragm over the hone, thus considerably narrowing the 
lumen of the ostium. (Fig. 224.) The size of the anterior wall 
depends largely upon the shape of the sinus, as is shown in Fig. 222. 



Fig. 224.—Position of sphenoidal ostium. Black line represents mucous membrane. 


2. The posterior wall is not subject to such variations as its 
fellows, as it is composed of thick cancellated hone tissue which 
does not usually yield to instruments of the calibre which are used 
in operating endonasally on the sphenoid sinus. When, however, 

547. Hansberg: Die Sondirung der Nebenhohlen der Nase. Mon. f. Ohrenhk., No. 
2, S. 48, 1890. 




SPHENOID SINUS. 373 


the sinus is of excessive size from over-reabsorption, all of the walls 
may suffer from the hyper-distention, and the posterior be reduced 
to such a thinness that careless or clumsy handling of instruments 
can cause a fracture or even perforation. Fortunately this 
anomaly is of rare occurrence. 

3. The superior wall is sub¬ 
ject to many vagaries not only 
in shape and position but also in 
extent and thickness. (Fig. 

225.) It is usually composed of 
thin but very compact bone, yet‘ 
may be quite thick, containing a 
considerable amount of cancel¬ 
lated structure. (Fig. 226.) 

Dehiscences have been reported 
in this structure in which the 
sinus mucosa lay in direct con¬ 
tact with the dura . 548 Accord¬ 
ing to the size and shape of the 
underlying sinus this wall is in 
direct contact with most im¬ 
portant intracranial structures: 
anteriorly, the right and left 
optic nerves and optic 
chiasm; 549 > 550 above or slightly 
posterior, the coronary sinus 
and pituitary body in the sella 
turcica. In this region the wall Fig . 225 . 
may be very thin, almost the 



—Varied conformations of superior walls of 
the sphenoid sinus. 


thickness of tissue paper, so that these structures come practically 
in actual contact with the mucosa of the sinus. The predisposition 
of intracranial complications is apparent when this condition pre¬ 
vails. The relation of the sella turcica to the cavity of the sinus is 
variable, depending upon the size and shape of the latter. Some¬ 
times it lies directly superior and other times posterior. (Fig. 225.) 

The intimate relation with the optic nerve (Fig. 221) is a pre¬ 
disposing factor to retrobulbar neuritis following purulent sphe¬ 
noidal sinusitis, particularly if a dehiscence, not unknown in this 
region, is present. 


548. Zuckerkandl: Anatomie der Nase, S. 339,1893. 549. Onodi: Der Sehnerve und 
die Nebenhohlen der Nase. 1907. 550. Loeb: Relation of Optic Nerve to Accessory 
Sinuses. Ann Otol., Rhin. and Lary., June, 1909. 






374 


THE ACCESSORY SINUSES OF THE NOSE. 



No regularity exists as to the thickness of bone separating the sinus from 
the nerve. Investigations 651 652 have shown that these measurements undergo great 
variations in different heads and even on different sides of the same head, as in one 
instance the nerve may lie almost in direct apposition to the mucosa of the sinus, 
while on the opposite side several mm. of spongy bone will intervene (Fig. 229). 

4. The inferior wall lies half within the nose, half within the 
choana (Fig. 4), forming a portion of the vault of the naso¬ 
pharynx. It is formed of compact bone seldom less than 3 mm. 
in thickness and may reach even up to 10 mm. It furnishes but 
one point of interest to the rhinologist, which is that the pharyngo- 
palatine artery traverses the outer angle of its inferior surface, 
which if wounded gives rise to 
severe and even fatal hemor¬ 
rhage. This fact must be borne 
in mind when operating in this 
vicinity. 553 

Through the inferior wall was 
formerly the operation of choice of 
several operators . 554 555 The opening 
was accomplished through the mouth 
with the aid of a laryngeal mirror. 

The method has been entirely aban¬ 
doned, as it was difficult to accomplish 
and by no means certain that the sinus 
would be found. 

5. External wall. This 

structure helps to form a por¬ 
tion of the middle cerebral Fig - 226 -- Enti re^ by can- 

fossa, and is in direct communi¬ 
cation with the cavernous sinus and internal carotid artery (Fig. 
227). It is one of the thinnest walls, being often of the thickness 
of ordinary writing paper, and if the sinus is large may show 
points of dehiscence, as have been frequently noted. On this 
account any manipulations in this vicinity with a curette are 
strongly contra-indicated. Numerous minute openings are visible 
in the bone for the passage of veins which anastomose with the 
cavernous sinus. 

6. Septal wall presents nothing of importance unless marked 
deviation occurs. (See Anomalies.) Dehiscence in this struc- 

551. Berger and Tyrmann: Die Krankheiten der Keilbeinhohle und des Siebbein- 
labyrinthes. Wiesbaden, 1886. 552. Onodi: The Optic Nerve and the Accessory Cavities 
of the Nose. Ann. Otol., Rhin. and Lary., March, 1908. 553. Myles: Trephining and 
Curettage of Sphenoid Sinus, profuse secondary hemorrhage requiring ligation of carotid. 
Laryngoscope, p. 293, 1903. 554. Ingals: Discussion on Accessory Sinuses. Trans. Am. 
Lary. Assn., p. 91, 1895. 555. Rolland: Montreal Med. Gaz., Aug., 1889. 







SPHENOID SINUS. 


375 


ture are rare, but have been occasionally noted. Complete absence 
of the septum has been reported, in which case but one ostium was 
present. The interior of the sinus usually contains irregularities, 
such as circumscribed recesses, ridges, spurs, and partial septa 
(Figs. 225, 227 and 230). These are much more commonly found in 
the sphenoid than in either the frontal or maxillary sinuses. 



Fig. 227.—Relation of internal carotid arteries to posterior sphenoidal wall. 


Right sphenoid sinus 


Internal carotid 
arteries 

Left sphenoid sinus 


PECULIAR ANOMALIES AND FORMATIONS. 



These are of three causes: (1) over-reabsorption, causing un¬ 
natural enlargement of cavity and prolongations; (2) deviations 
of inter-sinus septum; (3) over-extension of posterior ethmoidal 
cells. 

1 . Over-reabsorp- 
tion often causes the 
sinus to be prolonged 
in various directions: 

( a ) into the lesser 
wings and clinoid 
processes; ( b ) into 
the antero-inferior 
angle (palatine); (c) 
into the pterygoid 
processes ;(d) into the 
basilar processes of 
the occipital bone; ( e) 
into the rostrum of 
the sphenoid (rare). 

(a) Into lesser wings. (Fig. 228.) When reabsorption occurs 
in this direction the sinus encroaches upon the optic nerve, often 
to such an extent that the nerve comes to lie almost within the 
sinus cavity. The importance of this anatomical configuration 
cannot be overestimated, especially in connection with ophthalmic 


Fig. 228—Reabsorption of sphenoid sinus into the lesser wings 
of sphenoid bone. 







376 THE ACCESSORY SINUSES OF THE NOSE. 

complications resulting from infection of the nerve through in¬ 
flammation of the sinus mucosa, 

(b) Palatine. (Fig. 229.) When this recess occurs the max¬ 
illary sinus is in direct relation with the sphenoid, only a thin 
partition of bone separating the two cavities. This formation is 
rare, but when present is particularly favorable for operation on 
the sphenoid via the maxillary sinus route. 

( c) Pterygoid. (Fig. 230.) Reabsorption into these processes 
causes circumscribed depressions to be formed in the floor of 
the sinus. These are of importance in that they favor stagnation 
of secretion and lavage cannot be thorough. 

2. Deviations of Septum: In¬ 
equalities in the size and shape 
of the two sinuses are usually 
due to a deviation in the septum. 
This deviation may be slight and 
confined to the posterior por¬ 
tion or be so great as to prac¬ 
tically throw both sinuses into 
one large cavity with a small cell 
(representing the other sinus) in 
the anterior external portion. 
(Fig. 221.) Ordinarily the cur¬ 
vature is in the anteroposterior 
direction, but it sometimes also 
takes on a lateral deviation, thus 
placing one sinus in relation to 
the sella turcica, both the cavern¬ 
ous sinuses and both the optic 
nerves. Incomplete septa are frequently formed on the posterior 
sinus wall. These sometimes reach such dimensions as on section 
to give one the idea of the presence of a triple sinus. (Fig. 227.) 

3. Over-extension of Posterior Ethmoidal Cell: Occasionally 
one sphenoid sinus is poorly developed; a posterior ethmoidal 
cell pushing it downward and backward and occupying the place 
where the sphenoid is normally situated, forming a spheno-eth- 
moidal cell. (Fig. 231.) Under these circumstances the posterior 
ethmoid cell is then in relation to the superior structures (optic 
chiasm and pituitary body). Not infrequently this cell is in rela¬ 
tion to the sphenoid sinus of the opposite side, so that if diseased, 
it could easily communicate the infection to this cavity. 



Fig. 229.—Reabsorption into palatine fossa, 
and lesser wing of sphenoid. 


SPHENOID SINUS. 


377 


MUCOSA OF SPHENOID. 


The mucous lining of the sphenoid sinus is of a dull grayish 
color and extremely thin, but somewhat thicker than that of the 
frontal sinus being from 24 to 40 mm., denoting a lack of super- 


Posterior ethmoid 
celid 


Sphenoid sinus 



Frontal sinus 


Anterior ethmoid 
cells 


Fig. 230.—Reabsorption into pterygoid process. 


ficial vascularity. It does not adhere strongly to the underlying 
bone, but may readily be removed with the forceps. As with the 



other sinus three layers may be separated : mucous, submucous and 
periosteal. Glands are sparcely supplied except in the region 
of the ostium. 














378 


THE ACCESSORY SINUSES OF THE NOSE. 


The veins of the anterior wall empty into the nose through the 
ostium and into the ophthalmic, and those of the sides and roof 
into the coronary and cavernous sinuses. These form an im¬ 
portant factor in cerebral complications, for in the periosteal 
layer a network is present which penetrates the bony wall in 
numerous places and empties directly into the cavernous and 
coronary sinuses. The arterial supply is obtained from the 
spheno-palatine, pterygo-palatine and vidian arteries, the spheno¬ 
palatine through the ostium of the sinus and the spheno- and 
pterygo-palatine through the floor. 


Acute Inflammation. 

^Etiology. — The deep-lying position of the sphenoid sinus 
prevents the observation of primary changes in its mucosa; there¬ 
fore, little is known of the initial pathology of incipient sinusitis 
affecting this cavity. One factor, however, plays an important 
role, and that is the anatomical situation and peculiarities of the 
ostium. Being situated comparatively high upon the anterior 
wall in an unfavorable position for drainage, it resembles in some 
respects that of the maxillary sinus. The extreme narrowness 
of the spheno-ethmoidal fissures also predisposes to occlusion, 
particularly during the engorgement coincident to an attack of 
acute coryza. This would react in a double sense, for the inflam¬ 
mation from the nasal mucosa, would spread to that of the sinus 
as well as causing occlusion of the ostium with subsequent rarefac¬ 
tion. Under these circumstances we can state with a certain 
amount of assurance that the sphenoid is more or less affected 
during the course of every acute coryza. In the vast majority 
of these cases resolution of the sinus mucosa sets in as soon as 
the primary factor (the coryza) abates; whether the sinus dis¬ 
ease becomes chronic, depends largely upon the condition of the 
passages for sufficient drainage and aeration of the diseased 
cavity. 

It is rare that the sphenoid becomes acutely infected per se 
without some of the other accessory sinuses, particularly the pos¬ 
terior ethmoid cells, sharing the infection. The latter, however, 
by reason of their better drainage may entirely recover, leaving 
the disease isolated in the mucosa of the sphenoid. This is par¬ 
ticularly true in those cases which follow the infectious diseases, 
notably influenza. 


SPHENOID SINUS. 


379 


Pathology.— The pathological changes found in the mucosa of 
the sphenoid sinus differ but little from those in its fellows. Dur¬ 
ing the acute stage the entire mucosa in conjunction with that of 
the nose is involved, being intensely hvperaemic and swollen. As 
resolution in the former sets in, the sinus involvement generally 
continues, only returning to normal at a later period, thus giving 
rise to the impression that the sinus was primarily affected. 

Microscopic Histo-pathology .—But little difference is observed 
from similar conditions in the other sinuses, the mucosa, markedly 
cedematous, being 1-2 mm. thick, depending upon the intensity of the 
inflammatory process. In severe cases it may become so swollen 
as to convert the lumen of the sinus into a narrow slit. 555a Kound- 
cell infiltration is particularly marked beneath the epithelial layer, 
gradually shading off as the centre of the connective-tissue layer is 
reached. The vessels are dilated and full. 

Symptoms.— When the mucous lining of the sphenoid becomes 
greatly affected from the general inflammation of the nasal mucosa, 
certain symptoms ordinarily not present even with a severe cold 
in the head manifest themselves. 

The headache is more severe and becomes vaguely localized in 
the parietal and temporal regions, often radiating to one or both 
ears. Ocular symptoms, particularly tenderness of the eyeball, 
are often marked. Fever higher than usual with an ordinary coryza, 
sleeplessness, more or less dizziness and general malaise complete 
the chain of symptoms. The diagnosis is comparatively certain if 
these symptoms continue after the time one would reasonably expect 
those of an ordinary cold in the head to show signs of subsiding. 

Diagnosis. —From a rhinological point of view, the diagnosis 
of acute empyema is seldom made, for the following reasons: The 
general nasal mucosa is in a state of acute inflammatory hyper¬ 
trophy and the nasal cavities filled with secretion. Cleansing and 
shrinking with cocaine or adrenalin is only to he partially accom¬ 
plished, owing to the extreme tenderness of the parts, as well as 
to the lowered efficiency of these medicaments reducing the swell¬ 
ing in acute processes sufficiently to obtain views of the spheno¬ 
ethmoidal region.* * Even should the sinus be sounded and cat h- 


555a. Goetjes Pathologisches Anatomie und Histologie der Keilbeinhohle. Archiv. f. 
Laryng., Bd. 20, S. 129, 1908. 

* Coakley states: “ We have never been able in acute cases, even after the most thorough 
contraction of the nasal mucosa, to get a view through the nose of pus issuing from the 
normal opening of the sphenoid sinus.” The Sphenoid Sinus. Trans. Am. L., R. and O. Soc., 
p. 151, 1902. 



380 THE ACCESSORY SINUSES OF THE NOSE. 

eterized, it would be impossible to state with certainty whether 
pus was or was not present. The only reliable sign we have is the 
relief experienced by the patient after the catheterization and 
cleaning of the cavity. 

The general symptoms, at least at the commencement of the 
attack, furnish no clue pointing toward any particular sinus, as 
they are identical with, or perhaps only a slight exaggeration of, 
those commonly associated with the ordinary acute coryza. 

Treatment.— If after the acute stadium of a coryza the 
sphenoid is still found to be secreting purulent material with 
symptoms of retention, it will be necessary to further the out¬ 
flow by keeping the drainage passages as patulous as possible. 
This is best accomplished by daily opening the space between the 
middle turbinate and septum with cocaine-adrenalin solution, and, 
if necessary, introducing a cannula and washing out the sinus. 
As a rule, the first procedure will suffice to bring about a cure in 
ten days to two weeks. Aspirin in x grain doses every three 
hours will greatly facilitate resolution. Only in rare cases of 
threatened complications is an operative enlargement of the 
ostium necessary. 

Chronic Inflammation. 

-Etiology.— -The vast majority of acute inflammations within 
the sphenoid sinus recover either with or without direct treat¬ 
ment, but it must be remembered that following every attack 
there remains a greater predisposition for the sinus to become 
again involved at every fresh attack of coryza. Under these cir¬ 
cumstances we must consider that successive attacks of acute 
inflammation play no inconsiderable role in the {etiology of the 
chronic form. Any anatomical irregularities, such as deviated 
septa or pathological products, as polyps or hypertrophies, 
which contribute towards partial occlusion of the spheno-eth- 
moidal fissure, must also be classed as predisposing factors. 

Tuberculosis of the sphenoid is a rare condition but very occas- 
ionally has been found. 555b 

Pathology.— The changes seen in the mucosa during chronic 
inflammation depend upon the intensity of the pre-existing acute 
process. As a rule, regeneration has occurred in some parts 
leaving islands of inflamed or degenerated mucous membrane’ 
The areas of predilection f or these polypoid swellings would seem 

S55b. Keman: Tuberculosis of the Sphenoid Sinus. Laryngoscope, May, 1919.- 





SPHENOID SINUS. 


381 


to be in the region of the ostium and on the floor of the sinus. 
A peculiarity almost indigenous to this sinus is the tendency of 
the lining mucosa of the floor to become detached from the under¬ 
lying bone, thereby predisposing to osseous involvement from the 
inflammatory products lying in direct apposition to the bony floor. 

Microscopic Histo-pathology .—Unless the entire lining of the 
sinus is chronically affected, two conditions are usually found: 
(a) oedematous and (b) sclerotic. The first represents a condi¬ 
tion where the mucosa has but recently become infected or it has 
possessed sufficient regenerative power to partially combat the 
inflammatory process. The second, or sclerotic condition, repre¬ 
sents an advanced stage of pathological degeneration of the 
mucous membrane. In certain cases the mucosa is enormously 
thickened and has a velvety consistency. This inflammatory 
hyperplasia is, for the most part, uniform, as it is extremely rare 
that one finds true pedunculated polyps springing from the 
mucosa of the sphenoid sinus, although occasionally they have 
been encountered. 556-557 

Symptoms. —Perhaps no other sinus presents such a wide 
deviation in the subjective and objective symptoms as the chron¬ 
ically-diseased sphenoid. A chronic empyema of this cavity fre¬ 
quently exists without especial manifestations which would direct 
the attention of either the patient or examining physician to this 
portion of the cranium. On the other hand, sufferers from this 
disease have been so seriously affected as to seek relief from their 
misery with such extremes as suicide. 558 The subjective symp¬ 
toms, therefore, would depend upon certain conditions, and these 
conditions are at once referable to, and largely dependent upon, 
the drainage of the sinus. We can, therefore, roughly divide the 
cases into: (1) those with free drainage and insignificant 
symptoms, and (2) those with intermittent or deficient drainage 
and striking symptoms.* * 

1 . Those with Free Drainage: These are the cases which 
occupy not an inconsiderable proportion of those diagnosed in 
our dispensaries as rhinitis sicca, chronic rhinopharyngitis, post¬ 
nasal catarrh, etc. The actual condition present is a low-grade 
form of inflammation in the mucosa of the sphenoid sinus, dis- 

556. Zuckerkandl: Anatomie der Nase, Taf. 6, Fig. 1, 1892. 557. Kubo: Sur les 

Polypes Spheno-Choanaux. Archiv. Internat de Laryng., p. 390, 1913. 558. Schaeffer: 

Die Krankheiten der Keilbeinhohlen. Heymann’s Handbuch, S. 1186, 1900. 

* Both of these conditions can, of course, occur in the same case during the natural 
course of the disease. 



382 THE ACCESSORY SINUSES OF THE NOSE. 

charging a thin, mucopurulent secretion which, by reason of 
sufficient drainage, is never confined under pressure within the 
sinus. 

The most prominent symptoms in these cases are referred to 
the nasopharynx. The patients often complain of an almost con¬ 
stant postnasal discharge, which has a tendency to dry in the 
pharynx and is so difficult to dislodge that they are often required 
to use the finger for this purpose. The secretion has the con¬ 
sistency of pasty glue, and during the night forms into crusts. 
Discharge through the anterior nasal passages is scanty and often 
entirely absent, but occasionally, on violent blowing, some par¬ 
ticles may be observed in the handkerchief. 

Little occlusion or other sensations in the naris of the affected 
side are complained of by the patient; however, intermittent sub¬ 
jective cacosmia,which takes the form of either putrid or burned 
flesh, is often the cause of much discomfort. Headache, in the 
common meaning of the term, is absent; only occasionally is there 
a vague fulness behind the eyes, which tends to dull the faculty 
and create a condition of apathy. 

Examination of the nose anteriorly gives little data upon which 
to base, or even to surmise a diagnosis. The nasopharyngoscope will 
often prove a valuable adjunct here, as with its use it is frequently 
possible to see purulent secretion issuing directly from the sphe¬ 
noidal ostium (Plate 2b). On posterior rhinoscopy the choana is 
usually unnaturally moist, and there may be traces of crust forma¬ 
tion, but it is in the pharynx that we obtain a key to the situation. 

The mucosa of the posterior wall is either smooth and covered 
with a thin layer of dried secretion which gives to the parts a 
varnished aspect, or shows numerous crossed furrows between 
which the papilla are prominent. In either event, the condition is 
one that denotes inflammation due to the constant irritation from 
overflowing and drying secretion. The treatment of this condi¬ 
tion is to thoroughly flush out the sinus and keep the ostium as 
patulous as possible. This may be accomplished by the use of the 
long-bladed Killian speculmn, if no deviation of the septum 
towards the affected side is present. After thorough cocainiza- 
tion, particularly between the middle turbinate and septum, by 
means of pledgets of cotton gradually increased in size, the long 
blades of the speculum are passed between these two structures 
m the direction of the anterior sphenoidal wall until they meet 
with firm obstruction. The blades are gently but firmly sprung 


SPHENOID SINUS. 


383 


apart, thus crowding the middle turbinate against the lateral wall 
of the nose and bringing into view a portion of the anterior wall 
of the sphenoid. 

It requires considerable proficiency before much can be distinguished through 
the blades of this speculum, for the reason that only a very small slit at best is 
present and the reflected light must be carefully focused before it penetrates to 
the spheno-ethmoidal recess. 

The nasal sound is now introduced, and, by gently feeling the 
sphenoidal wall, the point is made to penetrate the ostium into 
the sinus. A long cotton carrier saturated with the strong adren¬ 
alin-cocaine solution is introduced into the ostium and allowed 
to remain several minutes until the mucosa around the opening 
is shrunken, thereby enlarging the ostium. At this point it is an 
easy matter to introduce a cannula and flush out the sinus. This 
treatment should at first be continued daily, later less frequently 
until the diseased sinus mucosa no longer secretes. 

The main difficulty with this treatment is the initial sounding 
of the ostium; however, once the anterior sphenoidal wall comes 
under our vision, the introduction of the sound into the sinus is 
only a matter of time and patience. 

2 . Those with Intermittent or Deficient Drainage: These are 
the cases in which both the subjective and objective symptoms are 
conspicuous. 

Headache .—This is one of the most prominent, at the same 
time one of the most unreliable, symptoms connected with the 
disease. Its presence depends upon the pressure of the secretion 
or of swollen mucosa within the cavity, in contradistinction to the 
sense of fulness behind the eye which is due to mechanical pres¬ 
sure from the actual oedema of the parts from venous stasis. As 
the internal sinus pressure, except in extreme instances, is not 
constant, it naturally follows that the headache must occur in 
periodical attacks, the severity of which is dependent upon the 
degree and prolongation of the pressure of the contained 
secretion. 

These attacks occur, as a rule, daily and last a varying length 
of time, from one to several hours, the patient being usually pros¬ 
trated for the time being. When remission occurs it is seldom 
complete, as a dull, indefinable ache continues until the next par¬ 
oxysm; in the severe cases it is this ache that reacts so upon the 
patient’s nerves as to make every succeeding paroxysm of pain 
anticipated with the greatest dread. 




384 


THE ACCESSORY SINUSES OF THE NOSE. 


The exact location of the head pains is impossible to deter¬ 
mine, as it varies with different degrees of inflammation as with 
different individuals, and even in similar cases is not localized in 
any definite spot. 559 

Generally speaking, it begins on the vertex and radiates down¬ 
ward to the temples and sometimes into the mastoid region. 
Again, it may centre in the occipital region, extending into the 
muscles at the nape of the neck. The deep-seated pain is located 
behind the eyeballs, and, when severe, even embraces these struc¬ 
tures. During the paroxysms or stage of retention the cephalalgia 
changes its character to an intense sickening throbbing, 
synchronous with the heart-beat. During the stage of quiescence 
it assumes more the character of a heavy pressure upon the top 
of the head. 560 Indulgence in alcohol or tobacco, constipation, or 
any slight irregularity which would tend to cerebral congestion, 
exercises a marked influence on the severity of the pain. Dizzi¬ 
ness and vertigo are often prominent, and manifest themselves 
on any sudden change of the position of the head, such as stoop¬ 
ing, sudden turning or jarring. 

Mental Symptoms .—As the sphenoid sinus lies in the closest 
relation to the base of the brain, certain cerebral manifestations 
appear as soon as pressure is established within the sinus. In¬ 
ability to concentrate the mind, with extreme aversion to mental 
work, commonly ushers in this train of symptoms. As the disease 
progresses these manifestations become more and more marked. 561 
(See General Symptoms, page 72.) 

Cacosmia is a frequent symptom, owing to the stagnation and 
putrefaction of secretion in the immediate proximity of the olfac¬ 
tory fissure. This symptom is more strongly marked during ex¬ 
piration through the nose than on inspiration. When the olfac¬ 
tory fissure is occluded through the hypertrophy of the middle 
turbinate, or polypoid excrescences, partial or complete anosmia 
sets in. 

Secretion. —A history of postnasal discharge can always be 
elicited from the patient, and, indeed, this symptom, or some symp¬ 
tom directly connected with this cause, is not infrequently the prin¬ 
cipal source of the patient’s complaint. The amount of the discharge 


559. Hinkel: Symptoms and Treatment of Chronic Empyema of the Sphenoid Sinus. 
Trans. Am. Lary. Assn., p. 93, 1902. 560. Skillern: Ein Fall von geschlossen Empyem, 
etc. Zeit. f. Lary., Bd. 1, S. 337, 1909. 561. Jonathan Wright! A Case of Isolated, Uni¬ 
lateral, Latent Empyema of the Sphenoid Sinus, with Delirium and Mental Symptoms. 
Operation and Recovery. Ann. Otol., Rhin. and Lary., Feb., p. 17, 1902. 




SPHENOID SINUS. 


385 


is not so troublesome as its continuation, particularly during the 
morning hours. Its consistency may vary from a mucoid to a foetid 
purulent, but, as a rule, it is thickly mucopurulent, with a decided 
tendency to dry on the surface and cohere to the nasopharynx, 
lateral walls of pharynx, and sometimes the fornices of the 
larynx. If this occurs in a given case it will always be seen in 
the morning on arising. 

Anteriorly little discharge escapes from the nose, as it would 
be obliged to pass through the narrow olfactory fissure in order 
to find its exit in this direction. Even violent blowing of the nose 
will not force it out anteriorly, though it succeed in dislodging the 
secretion from the spheno-ethmoidal region. 

Sore throat is practically always present, being one of the 
cardinal symptoms, and, indeed, is often the first thing that calls 
the attention of the rhinologist to some postnasal disturbance. 
This pharyngitis is often unilateral, manifesting itself on the 
diseased side. 

Hoarseness, and, in rare cases, intermittent aphonia, is occa¬ 
sionally met with, particularly in those cases in which the post¬ 
nasal discharge is so profuse as to collect around the laryngeal 
structures. There the arytenoids become irritated, and, finally, 
chronically cedematous, causing interference with .the function of 
the inter-arytenoidal muscles and, consequently, with the mobility 
of the cords. In all cases of vocal disturbances associated with 
nasal catarrh the sphenoid sinus and posterior ethmoidal cells 
should be thoroughly investigated. 

Bronchial and gastric disturbances, also occurring concomi¬ 
tantly with this affection, have already been referred to. (See 
General Symptoms, page 69.) Tinnitus aurium, without percepti¬ 
ble diminution of hearing or changes in the aspect of the ear¬ 
drum, associated with this disease are due to the reabsorption of 
toxins, causing incipient neuritis of the auditory nerve. 

Ocular Symptoms , 562 —Scintillating scotoma is most frequently 
observed. Enlargement of the blind spot is almost pathognomonic 
for some disturbances in the posterior ethmoid or sphenoid sinuses. 
Exophthalmos, when present, is due to either (a) oedema of the 
orbital tissue from some obstruction to the returning venous 
circulation; (b) paralysis of the external ocular muscles from 


562. Schroeder: Ocular and Orbital Symptoms in Diseases of the Sphenoidal Cavity. 
Archives of Otology, p. 277, 1907. 



386 


THE ACCESSORY SINUSES OF THE NOSE. 


toxaemia, or (c) retrobulbar swelling due to extension of the purulent 
process. These may also occur in combination. 

Objective Symptoms .—Anterior rhinoscopy: The nose pre¬ 
sents a totally different picture than that encountered with acute 
inflammation. On superficial inspection no striking changes are 
for the moment visible, but on careful examination several patho¬ 
logical conditions will be brought to light. On directing the atten¬ 
tion to the olfactory fissure, it will be noted the mucosa in this re¬ 
gion is distinctly hyperplastic. The classical symptom of purulent 
secretion exuding between the middle turbinate and septum, 
thus occluding the olfactory fissure, is not always present, but 
is sometimes represented by a small crust in this locality. On re¬ 
moving this crust with a cotton mop a more or less purulent secre¬ 
tion will be seen beneath, which will reappear on wiping away. 
If the turbinate is so hypertrophied that it presses tightly against 
the septum, this symptom will be entirely lacking, for under these 
circumstances the secretion, finding no anterior outlet, will be 
directed backward into the choana with the main body. Only in 
exceptional cases, where the olfactory fissure is abnormally wide, 
do we meet with free pus flowing out and down along the side of 
the septum to the floor of the nose. 

Hyperplasia of the septal and middle turbinate mucosa is always 
marked when the secretion finds its way in this direction. Some¬ 
times the hyperplasia follows a direct course towards the anterior 
sphenoidal wall. Occasionally the mucosa of the septum opposite 
the anterior end of the middle turbinate is so swollen as to give one 
the impression that a localized abscess existed. 563 This hyperplasia 
is due to the fact that the secretion from the sinus dries on this por¬ 
tion of the septum, causing continued irritation to the underlying 
mucosa. 

Posterior Rhinoscopy: As the secretion must escape through 
the choana, we would naturally seek, in this locality, for some trace of 
its existence. At this point I must state that in my experience I 
have rarely seen the nasopharynx filled with free pus and crusts, as 
has been so often described in text-books. Only in rare instances 
has this, been noted, and never in the profusion so commonly be¬ 
lieved. Occasionally, particularly in the morning, one can observe 
isolated crusts of varying size in the nasopharynx, particularly on 
the posterior wall. On removal these appear to have been floating 

Sphe^dda^s^BiftMed'.'joum.^ voT'l^pAwsfl^OS.* ° f in the 




SPHENOID SINUS. 


387 


on a layer of pus. 'When this condition is present it is almost pa¬ 
thognomonic of posterior sinus disease. The average case at the 
time of examination shows a slight mucopurulent or purulent line 
coming down oyer the posterior end of the middle turbinate. As 
for the vault being filled with crusts, this has never come under my 
notice. Occasionally pus will accumulate in such a manner as to 
give one the impression that suppurative inflammation has occurred 
in the pharyngeal tonsil. 

. Tim greatest accumulation is present in the morning, directly on 
arising, as during the night the secretion has a better chance to leave 
the sinus on account of the lowered position of the ostium. 

Changes are invariably present on the posterior and often the 
lateral pharyngeal walls. Pharyngitis sicca is perhaps the most 
common, the following variety being pathognomonic of sinus dis¬ 
ease. The posterior wall of the pharynx is dry and smooth, having 
an appearance as though covered with a thin coat of shellac. The 
condition seems to be intensified as it disappears upward behind 
the uvula, while there is a gradual shading off into comparatively 
healthy mucous membrane as it descends toward the larynx. This 
is readily explained when we consider that the secretion comes from 
above and, being hawked out, but a comparatively small quantity 
descends below the pharyngeal orifice. 

Another form of pharyngeal inflammation, which is also pathog¬ 
nomonic, is known as pharyngitis lateralis. In this variety the mucosa 
at the junction of the posterior and lateral walls shows a marked 
hypertrophy, being hyperaemic and swollen so that it has the appear¬ 
ance of a raised tract about half the size of an ordinary lead-pencil, 
situated on the diseased side. It is along this tract that the secretion 
finds its way into the throat. Free purulent secretion in the choana 
and throat is more often missed than met with; therefore, its ab¬ 
sence proves nothing, so far as chronic sinusitis is concerned. A 
symptom which is sometimes of import is a foul smell to the breath. 
This is most perceptible to the examining physician and does not 
resemble any other nasal condition. It is a sweetish, foetid odor, and 
when present is pathognomonic of purulent sinus affection. 

Diagnosis.— Let us suppose we had a case that presented cer¬ 
tain symptoms (excessive postnasal discharge, parietal and 
occipital headaches, and purulent secretion in olfactory fissure) 
which led us to suspect disease of the sphenoid sinus. What 
course do we pursue in order to arrive at a positive diagnosis? 
For this purpose one and only one condition confronts us, 


388 


THE ACCESSORY SINUSES OF THE NOSE. 


namely, we must prove that the purulent discharge not only issues 
from, but is secreted by, the mucosa of the sphenoid sinus. As the 
pus usually makes its appearance anteriorly between the middle 
turbinate and septum, let us first apply our investigations to this 
region. Before attempting any manipulations we must thoroughly 
apply the strong cocaine-adrenalin solution, not only for its anaes¬ 
thetic qualities, but also in order to gain as much room as possible. 
After anaesthetization is complete the naris is thoroughly cleansed 
with a warm salt solution. Remembering now the cardinal prin¬ 
ciple that pus must shortly reappear after being removed if 
coming from a reservoir or sinus, we take a cotton mop and 
gently cleanse the olfactory fissure. If the secretion has formed 
from a localized inflammation of the mucosa it will not reappear. 

During the waning of an acute cold, pus is often seen in the olfactory fissure. 

Let us suppose that it reappeared in the same position, our 
next step is to follow the flow to its origin. The extreme narrow¬ 
ness of the olfactory fissure prevents this; therefore, we must 
endeavor to artificially dilate the parts until the sphenoidal ostium 
is brought into view. The mucosa of the middle turbinate and 
septum is exquisitely sensitive; therefore, much care and patience 
will be expended before this is finally accomplished. We begin 
by introducing a small cotton mop saturated with cocaine-adren¬ 
alin between the middle turbinate and septum, forcing it back 
until some resistance is felt. This is allowed to remain a few 
moments in situ, then removed and a large one inserted, the pro¬ 
cedure being continued until the mop passes back and rests 
against the anterior sphenoidal wall. 

Thus we not only anaesthetize the parts, but cause a slight 
dilation as well. The long-bladed Killian speculum is now intro¬ 
duced until the ends are in approximation with the spheno-eth- 
moiaal fissure and the blades gently sprung apart. If this manip¬ 
ulation has been properly accomplished, no blood will be seen 
between the blades; if, however, the tips have lacerated the 
mucosa of the anterior sphenoidal wall, the entire field will be 
swimming in blood, making further examination difficult, not to 
say unavailing. Supposing the introduction of the speculum has 
been successfully accomplished, we are enabled to see a very 
small portion of the anterior wall of the sphenoid under reflected 
light. Only in exceptional cases does the ostium come under our 
vision, on account of its anatomical situation in the splieno-eth- 


SPHENOID SINUS. 


389 


moidal recess; however, an attempt should be made to find it by 
first cleansing the anterior wall with the cotton mop and, if still 
invisible, by resorting to the sound. 

The sound having been introduced in the usual manner (for 
technique see page 382), on withdrawing it we should note whether 
pus follows or any trace is present on the tip of the instrument. As 
a negative finding proves nothing, in order to ascertain whether 
pathological secretion is actually within the sinus it is necessary to 
introduce a catheter and, if the ostium be visible, forcibly blow air 
into the cavity, otherwise flush out the interior with normal salt 
solution. If pus appears on either of these procedures our diag¬ 
nosis is made. (See Differential Diagnosis, page 384.) 

Grayson 563a does not lay great stress on finding the ostium for purposes of diag¬ 
nosis. When it is suspected that the sinus contains pus he uses a small cone-shaped 
burr on the end of a long shank and makes an opening in the anterior sphenoidal wall 
at the most favorable locality. (See p. 384.) 

Cases in which it is impossible to obtain a view of the anterior 
sphenoidal wall.—In more than 50 per cent, of the cases anatomical 
peculiarities, such as deviated septum, abnormally narrow nose, 
and enlarged middle turbinate, are present which absolutely prevent 
the application of the long-bladed Killian speculum. Sounding 
followed by lavage, depending upon the sense of touch, is seldom 
successful, and when effectively accomplished is most unsatisfac¬ 
tory, for the following reasons: We do not know that purulent 
secretion is in the sinus, but depend upon the returning flow from 
the syringe to contain particles of pus. As a matter of fact, unless 
there is a considerable quantity of thick, purulent secretion present, 
little evidence will be seen with the returning fluid, as the sinus lies 
at such a distance from the nasal orifice that most of the pus will be 
arrested in the various interstices of the posterior ethmoidal region 
and in the nasopharynx. Under such circumstances, but one course 
lies open to us, and that is to lay bare the anterior sphenoidal wall— 
a procedure which will necessitate the removal of some of the intra¬ 
nasal structures. In the majority of instances this will mean 
resection of the posterior half of the middle turbinate or resection of 
a deviated septum, or both, as the case may be. In order to arrive 
at a definite diagnosis we are perfectly justified in these procedures, 
as in the event of disease being present a step in the therapy has al¬ 
ready been applied, while, should the parts be found healthy, no 
particular damage has been done. 

563a. Grayson: The Exploratory Opening of the Sphenoid Sinus. Penna. Medical 
Journal, p. 558, April, 1913. 



390 THE ACCESSORY SINUSES OF THE NOSE. 

Mucocele. 

This condition occurs but rarely, as only nine cases have been 
reported up to the present. 56313 It is always associated with some 
inflammation in the spheno-ethmoidal region (usually posterior eth- 
moditis), which also accounts for its origin, the sphenoidal ostium 
being first closed by the spread of the neighboring inflammation. 

The disease begins insidiously and runs a chronic course with 
mild symptoms which only become significant after the mucocele 
has attained some considerable size. 5630 The symptoms, when 
present are those referable to the eye such as beginning disturb¬ 
ances of vision from pressure with or without exophthalmos, those 
to .the nose such as occlusion to respiration on affected side; very 
rarely deformity and displacement and those to the head as head¬ 
ache and dizziness on stooping or exertion. These symptoms are 
rarely present together, at least in the early stages, but as a rule 
are limited to a single phase as in one case there will be no occular 
disturbance, in another the headache will be absent, while in the 
third, nasal manifestations will be lacking. 

The early diagnosis is on this account, difficult even the X-ray 
plates, on account of the rarification of the osseous walls, being 
.difficult to properly interpret. A complaint of intranasal tension 
of indefinable character is highly significant and of great diag¬ 
nostic value. 

Treatment consists in opening the cavity at the earliest possible 
moment. This will not only give relief, as far as the actual symp¬ 
toms are concerned, but also by lifting the pressure from the eye, 
remove the cause of the gradual diminution in the vision. The 
sight, however, will rarely return even in those comparatively 
recent cases and never after a few months duration of constantly 
increasing pressure upon the optic nerve. 

Sounding the Sphenoid Sinus. * 

In the normal nose it is difficult to sound this sinus, for the fol¬ 
lowing reasons: 1. The posterior half of the middle turbinate com¬ 
pletely hides the anterior sphenoidal wall from view. 2. The 

563b. VanderHoeve: Mucocele of the Sinus Sphenoidalis. Acta Oto-Laryngologica, 
vol. 2, p. 505, 1921. 563c. Rhese: Ueber Keilaeinhohlen Mukozele. Zeit. f. Ohrenhk., 
Bd. 64, A 169, 1912. 



SPHENOID SINUS. 


391 


spheno-ethmoidal recess being a variable structure, the ostium has 
no constant place of situation. 3. The parts are exquisitely sensi¬ 
tive and do not bear well the various manipulations of the sound. 
Under certain conditions, however, this manoeuvre may be accom¬ 
plished even though the ostium is not visible. Naturally, the most 
favorable conditions for sounding are: (1) when the middle turbi¬ 
nate lies closely unrolled against the lateral nasal wall; (2) when a 
deviation of the septum occurs toward the opposite side. 

TECHNIC OF SOUNDING. 

Before attempting to introduce the sound in the spheno-eth¬ 
moidal region it is always advisable to cocainize the parts. If there 
is sufficient space between the middle turbinate and septum this can 
be accomplished by means of a cotton carrier saturated with a 20 
per cent, cocaine solution; if not, a 2 per cent, spray may be used. 
A fine, flexible, graduated sound with measurements at 7, 9 and 11 
cm. from the tip is now introduced into the nose between the septum 
and middle turbinate, crossing the later structure exactly at its 
centre, and carried backward until it is arrested by coming in con¬ 
tact with the anterior sphenoidal wall. 

The most important step of this manipulation is to cross the middle turbinate 
at a point corresponding to its centre. If the sound is carried too far forward 
the lamina cribrosa will be touched, while if it is directed too far backward the 
point will come out with the choana. 

The ostium of the sinus is now sought for by gently probing 
in all places accessible to the point of the somid, using as little 
force as possible, as the anterior wall is extremely thin in this 
locality and may easily be broken into—an accident to be care¬ 
fully avoided unless it is unmistakable that the sinus is diseased. 

Much has been said regarding the danger of perforating the cribriform plate 
during this manoeuvre. This is more apparent than real, for that structure lies too 
far forward and the posterior portion of the roof of the olfactory fissure is quite 
thick at its junction with the sphenoid sinus and does not readily yield to an in¬ 
strument as delicate as a probe. Indeed, I have intentionally endeavored to puncture 
this plate on numerous cadavers, but have failed in every instance, the sound bend¬ 
ing before infraction of the bone was accomplished. 

In the majority of instances this will fail to find the opening, as 
the sound, being straight, cannot penetrate into the depths of the 
spheno-ethmoidal recess where the ostium is probably situated. 


392 


THE ACCESSORY SINUSES OF THE NOSE. 



Under these circumstances it will be necessary to entirely withdraw 
the instrument from the nose and bend the tip slightly outward 
and downward: outward in order to penetrate the recess, downward 

as the ostium is usually situ¬ 
ated below the junction of the 
roof and anterior sinus wall. 
The sound is again introduced 
and the ostium sought for by 
probing with the new carved 
tip. Sometimes this will suc¬ 
ceed, sometimes fail. How do 
we then know that the point of 
the sound is actually within the 
sinus ? There is where the 
measurements on the sound 
have their importance. The 
distance from the anterior in¬ 
ferior nasal spine to the anterior wall of the sphenoid is 7-8 cm. 
(Fig. 232). 564-565 Even in the largest heads these measurements 
are rarely exceeded.* * The first notch on the sound represents 7 cm. 
If the sound does not enter beyond this mark it is doubtful if one is 
beyond the anterior sinus wall. If, however, this mark is exceeded, 
the sound disappearing to the second notch, we are either in the 
sphenoid sinus or a sphenoid-ethmoidal cell, provided the direction 
across the cavity has been true. 


Fig. 232.—Sounding the sphenoid sinus. In 
this instance the ostium is situated much lower on 
the anterior wall than is usually the case. 


It sometimes occurs that the sound penetrates up to and even past the 11 cm. 
notch after the tip has passed through the ostium. Under these circumstannces we 
at once know that the sinus extends far backward on that side. 

Unfortunately, in the majority of cases our attempts at sound¬ 
ing mil prove futile under the usual conditions, for not only have 
we the normal difficulties to contend with, but also those resulting 
from inflammation (hypertrophies, polyps, and crusts). The 
Killian speculum may be used to partially overcome these difficul- 


564. Schaffer (402), S. 906. 565. Hansberg: Die Sondierung der Nebenhohlen der 

Nase (Keilbeinhohle). Monat. f. Ohrenhk., S. 50, 1890. 

*The distance between these two points rarely exceeds 8 cm.; indeed if one has passed 
a sound in this direction 8 cm. in small heads and 9 cm. in large heads, measuring from the 
anterior inferior nasal spine, the ostium of the sphenoid sinus is almost certain to have been 
penetrated. 



SPHENOID SINUS. 


393 


ties, blit, as with the frontal sinus, it will probably be indicated to 
remove a portion of the middle turbinate; while with the sphenoid 
it will be the posterior half of this body. The object of sounding 



Fig. 233a.—Grayson’s method of opening the 
sphenoid sinus with a hand burr. 


Fig. 233.—Jacob’s method of sounding and catheter- 
izing the sphenoid sinus. 


In difficult cases, particularly when hypertrophies and polyps obstruct the 
view but are passable to the sound, the nasopharyngoseope can often be conveniently 
used. It is first passed through the inferior nasal passage and the anterior 
sphenoidal wall inspected. Keeping the eye to the instrument, the sound is 
passed above it until the end is seen through the scope to strike the anterior wall. 
Manipulation of the sound is made under guidance of the scope until the tip is 
observed to penetrate the ostium into the sinus cavity. 

Hand-Burr: The idea of this instrument was conceived by 
Grayson 565a for the purpose of making an exploratory opening into 
the sinus which can also be utilized for therapeutic purposes. The 
perforation is made as close as possible to the angle of junction of 
its floor with its internal wall (Fig. 233a) and is 2 mm. in diameter, 
a size claimed to be quite sufficient to permit the escape of any fluid 
from within the sinus or the introduction of the jaw of a biting 
forceps for the purpose of enlarging the breach. He^contends that 
the opening is perfectly situated for drainage and one through 
which the cavity can be thoroughly cleansed, and also advocates 
beginning the radical operation at this point. 

Advantages. —Anatomic: All things being considered, it attacks 
that portion of the sinus wall most available to instrumentation. 
It is easy to accomplish as far as the actual manipulations are con- 


565a. Grayson: The Exploratory Opening of the Sphenoid Sinus, Laryngoscope, p. 









394 


THE ACCESSORY SINUSES OF THE NOSE. 


cerned. It can be applied when the anterior face of the sinus is 
difficult of access. 

Disadvantages. —Anatomic: The thickness of the sinus wall as 
well as the hypertrophy of the diseased lining mucosa may prevent 
reliable conclusions from being drawn as the pathologic state of 
the interior. Even if the sinus contained large quantities of pus, 
the opening is so small that during lavage such a slight amount 
would be brought out at once that it would be lost in the interstices 
of the posterior nares before it appeared in the pus basin. Another 
factor: the burr is so short and dull that it enters so slowly as to 
easily lift up the thickening mucosa from the underlying bone, thus 
causing the attempts to irrigate abortive. Accepting, however, that 
the exploration had been successful and pus had been found, the 
opening is too small to permit sufficient drainage or effective treat¬ 
ment, which are made more difficult by the tendency of the wound to 
close, which it does, as Grayson admits, in twenty-four hours. 

As a starting point for the radical operation, such a small open¬ 
ing (2 mm.) particularly when the bone is thick, as it is so prone to 
be in this particular locality, offers but a poor hold for any sphenoid 
forceps except possibly the Faraci, which one would hesitate to 
use on account of the grave risk of breaking the point off in the sinus. 

Differential Diagnosis.— Owing to the manifold and curious 
symptoms that occur during the course of a chronic purulent inflam¬ 
mation of the sphenoid sinus this disease often remains undiag¬ 
nosed, being confused with some condition associated with the 
throat, bronchi, or even the general system (anaemia, neurasthenia, 
etc.). In these doubtful cases one local symptom, when elicited, is 
the keynote to the situation, i.e the postnasal discharge. Unfor¬ 
tunately, one is obliged to rely largely upon the description of the 
patient as to the amount and character of the discharge, but, should 
this symptom be complained of, it must be followed up to the end 
in order to determine the exact source. 

A chronic postnasal discharge, other things being equal, 566 
results usually from: 1. Inflammation of the sphenoidal mucosa. 
2. Inflammation of the posterior ethmoidal labyrinth. 3. Com¬ 
bined inflammation of both sphenoid and ethmoid. 4. Purulent 
inflammation of the nasopharynx (adenoids, lues, tuberculosis, 
etc.). Let us suppose a patient presented himself with subjective 
symptoms of posterior ethmoidal or sphenoidal suppuration with 
a postnasal discharge which we are able to trace to the spheno- 

566. Empyema of the sinuses of the first series, in/which the purulent discharge finds 

its way backward into the choana, is, of course, not taken into consideration. 



SPHENOID SINUS. 


395 


ethmoidal region. Posterior rhinoscopy shows us that the source 
is not in the nasopharynx, but somewhere above, as the purulent 
secretion appears to be coming down over the posterior end of 
the middle turbinate. Anterior rhinoscopy, even after the 
removal of a portion or all of the middle turbinate, only shows us 
that pus is present in the spheno-ethmoidal region, but not par¬ 
ticularly located in any individual sinus. As with the maxillary 
in the anterior sinuses, in this instance we first turn our attention 
to the sphenoid. Our first thought is, of course, to find the ostium 
or, in certain cases where this is impossible, to break in the 
anterior wall with a dull curette. If, however, the ostium is seen, 
the anterior wall is wiped off with a cotton pledget and the parts 
again inspected. Suppose we are still unable to find any pus 
around the sinus orifice. 

This may be either due to the thick consistency of the pus, the small size of the 
ostium, or to the fact that no secretion is present within the sinus. Under any cir¬ 
cumstances our next procedure is to introduce a small cotton pledget saturated with 
cocaine-adrenalin solution within the ostium and allow it to remain several minutes. 


We now cause the patient to bend the head over so that the 
chin rests upon the chest and remain a few moments in that 
position. After a varying length of time (two to five minutes) the 
spheno-ethmoidal space is again examined, and if any patho¬ 
logical secretion is in the sinus it will be seen exuding from the 
enlarged ostium. Does this finding warrant the diagnosis of 
sphenoidal empyema! No, as we are not certain that the pus 
did not trickle in from the posterior ethmoidal cells. 


As a matter of fact this possibility is largely exaggerated, for in the vast ma¬ 
jority of instances where pus is seen exuding from the sphenoidal ostium, particu¬ 
larly under pulsation, the mucosa of the sphenoid is responsible for the secretion. 

Accepting, then, the possibility of a sphenoidal sinusitis, how 
can one differentiate from which region the purulent secretion 
occurs ? 567 In order to accomplish this with a more or less degree 
of certainty, it is necessary to cleanse the sphenoid as well as the 
entire postnasal space, so that no secretion is visible in either 
anterior or posterior rhinoscopy. After this has been done, the 
patient should either lie on the back or in a sitting position, lean¬ 
ing the head backward until the eyes point toward the ceiling, and 
keep the position for some minutes. 

The rationale of this manoeuvre is to place the parts in such a position as to 
favor the drainage of secretion from the posterior ethmoidal cells into the spheno¬ 
ethmoidal fissure. A glance at Fig. 26 will at once make this apparent. _ 

-567. In the experience of Rhese (Entzundungen der Siebb. und der Keilbeinhohle 

Arch. f. Lary., Bd. 24, S. 426, 1911) empyema of ethmoid coexisted with Sphenoid empyema 
in 66f per cent, of all cases. 




396 


THE ACCESSORY SINUSES OF THE NOSE. 


The patient is again examined, using the long Killian speculum 
if necessary, and if secretion is seen in the vicinity of the sphe¬ 
noidal wall where it was absent immediately before, we car? safely 
assume that it has its origin in the posterior ethmoidal cells, as 
it would have been impossible for the mucosa of the sphenoid to 
have secreted such a quantity in so short a space of time. A 
negative result is not necessarily of value, as the cells may be empty 
at the time of examination. 

Let us suppose, then, that we found purulent secretion not only 
in the sphenoid sinus, but externally to it as well. What are the 
possible conditions that can confront us! 1. An empyema of the 
posterior ethmoidal labyrinth and sphenoid sinus. 2. An empyema 
of the posterior ethmoidal labyrinth in which there has been a 
seepage of pus into a healthy sphenoid sinus. 

What means have we at hand to differentiate between these 
two conditions! To accomplish this successfully it is absolutely 
necessary that we have a free view into the spheno-ethmoidal 
space; at least, that the sphenoidal ostium is freely visible. This 
being the case, after thorough lavage and cleansing of this 
region, including the sphenoid cavity, a pledget of cotton or gauze 
is introduced into the ostium of the sphenoid, making it inper- 
vious to the passage of secretion, and further examination de¬ 
ferred until the following day. On the return of the patient he 
is closely questioned whether any unnatural or severe headache or 
other cranial symptoms have developed in the interim. 

The structures lying anteriorly to the sphenoid are thoroughly 
contracted with cocaine and adrenalin in order to obtain the best 
possible view of the deeper regions, care being taken not to dis¬ 
turb in any way the plug introduced the previous day. Close ex¬ 
amination of the spheno-ethmoidal region will now show one or two 
things: either pus is absent or it is present, covering the external 
surface of the plug. A positive diagnosis is now possible. If pus 
is present, the posterior ethmoid cells are diseased and have 
throw off the secretion which covers the anterior wall of the 
sphenoid;* To discover whether the sphenoid shares in the 
inflammation with the posterior ethmoid cells is now a simple 
matter. After cleansing the posterior nares of all crusts and 
purulent secretion, the utmost care being taken not to disturb the 
location of the plug, under direct vision the cotton is seized with 

♦If any doubt exists as to whether leakage occurred through the cotton plug, this 

manipulation may be repeated. 



SPHENOID SINUS. 


S97 


tlie forceps and quickly removed, noting instantly whether secretion 
of any kind escapes with its withdrawal. 

If the ostium appears clean and the sinus cavity is found to he 
dry and empty, we can exclude the sphenoid from any participa¬ 
tion in the affection. If, however, pus appears welling from the 
ostium, we are certain that it was secreted within the cavity, and, 
consequently, disease is present in the sinus. Under these cir¬ 
cumstances the diagnosis would be combined posterior ethmoidal 
and sphenoidal sinusitis. 

EMPYEMA OF A SPHENO-ETHMOIDAL CELL. 

The occurrence of such a condition would be most confusing, for one would 
encounter pus coming from above the normal ostium of the sphenoid. Such a 
case would probably remain unrecognized as such until operation disclosed an 
apparently horizontal partition dividing the sphenoidal sinus into a superior and 
inferior compartment. 

EMPYEMA OF THE POSTERIOR HALF OF A DOUBLE MAXILLARY 

SINUS. 

Recollecting that the ostium of the posterior half of a double maxillary 
sinus finds itself in the superior nasal passage, an empyema affecting such a 
cavity could early be confused with sphenoidal disease. Hajek (p. 364) mentions 
such a case, and was only after many days with the greatest difficulty, able to 
make a correct diagnosis. " This was accomplished by tamponing the sphenoid and 
sounding the posterior ethmoid cells, thereby assuring himself of their healthy 
condition. The sound was then passed into the ostium of the posterior half of 
maxillary sinus. This cavity was later opened through the socket of the second 
molar tooth. 

Prognosis. —If once the mucosa of the sphenoid sinus becomes 
chronically diseased it is very doubtful if spontaneous regenera¬ 
tion ever occurs, even though naturally favorable conditions super¬ 
vene. There is no doubt, however, that it may at times become so 
latent as to give even the patient the impression that a cure has 
' resulted. This period of latency may last until some unfavorable 
condition arises (exposure to wet feet, change in the weather, etc.), 
when the inflammation again breaks forth with renewed vigor. So 
long as there is free drainage existing little danger to life, or even 
of complications, exists, but as soon as any interference to the free 
outflow of the secretion manifests itself, at that moment we have 
an {etiological factor for serious consequences. 

The formation of these obstructions can almost be designated 
as autogenetic, for, while the anterior sphenoidal wall exhibits 
a marked tendency to osteoporosis with enlargement of the natural 
ostium during the course of a chronic infection, the mucous mem¬ 
brane, of the sinus and spheno-ethmoidal fissure by reason of the 


398 


THE ACCESSORY SINUSES OF THE NOSE. 


constant irritation of the escaping pus, becomes distinctly hyper¬ 
trophic. On account of the narrowness of the spheno-etlynoidal 
fissure these hypertrophies can present a serious obstacle to the 
escape of the continually-forming secretion within the sinus. Stag¬ 
nation of the secretion^ even though only partial, seems to heighten 
the virulence of the infection. Whether this is due to an actual 
increase in the virulence of the organism or to a decrease in the 
resisting power of the sinus mucosa is a debatable matter. In all 
probability, both of these factors act in common. 

If the ostium be of sufficient calibre to insure the free outflow 
of any secretion which may form, the patient may go for months, 
and even years, without any other disturbance than that which 
naturally follows the escape of more or less purulent or muco¬ 
purulent discharge into the nasopharynx. This is well illustrated 
in those cases which have undergone operation. It is notable 
to remark the frequency with which operated patients become 
reinfected without exhibiting the primary subjective symptoms 
(headache and mental disturbances) incident to the disease. 
Reviewing these facts, we can state that prognosis of chronic 
sphenoidal suppuration is good, so far as life is concerned, pro¬ 
vided that the drainage passages be kept patulous. The prog¬ 
nosis for cure is good if an opening of. sufficient size is made in 
the anterior wall of the sinus that will enable one to reach all 
portions of the diseased mucosa, but the proneness of the lining 
mucosa to constant, reinfection is a probability which must not 
be overlooked. 

Complications. —Owing to the deep lying situation of the 
sphenoid sinuses and their intimate relation to the base of the 
brain, cavernous sinus, and the optic chiasm and nerve-trunk 
(Fig. 35), complications embracing these structures as a result 
of prolonged or virulent inflammation of the sinus mucosa are 
more frequently observed than with the other sinuses. 

Several causes may be ascribed as responsible for their occurrence, as: a. in¬ 
timate anatomical relation of the walls of the sinus to these structures, b. The 
hidden position of the sinus causing the disease to be unrecognized, c. The defects 
and dehiscences in the bony walls, thus bringing the sinus mucosa in direct contact 
with intracranial structures. 

Chief among these, and, indeed, almost peculiar to this cavity, 
are thrombosis of the cavernous sinus and affections directly 
implicating the optic nerve (retrobulbar ). 567a - b 



SPHENOID SINUS. 


399 


RETROBULBAR NEURITIS 

This affection constitutes the most common occular complication one meets with 
resulting from sphenoid sinusitis.*"* The usual history of such a case is a gradual 
diminution of vision most frequently on one side which is progressive and unless 
cheeked, results in complete blindness. 

Etiology. The process was formerly attributed to direct pressure on the optic 
nerve lying m close proximity to the sinus, in other words, due to an extention of 
the inflammation from the sinuses to the optic nerve but recovery so often rapidly 
followed the evacuation of the pus or simple aeration of the sinus, that it would point 
to a toxic neuritis being the cause rather than to a purely inflammatory condition 
resulting from direct extention by continuity. However, the following conditions 
may be concerned: 


1. Direct spreading of the infection from the sinus mucosa to the sheath of the 
optic nerve. 

2. Toxemia from infection in the sinuses. 

3. Hyperplasia beginning in the sinus mucosa. 

White o6 ‘J believes the hyperplasia more a predisposing factor than the 
principal etiologic condition and that poor ventilation and faultv drainage appear 
to be the more important factors. I agree with this postulation in the main although 
one must always admit the presence of some sort of an infection. The most 
prominent symptom is of course loss of vision but neither its onset, process or 
degree of intensity, shows uniformity which could be considered characteristic • how¬ 
ever, when an inflammatory process attacks that portion of the optic nerve which is 
contained m the optic foramen, the symptoms are more or less definite. These 
consist of foggy vision affecting one eye rapidly progressing until complete blind¬ 
ness supervenes. 56 * b 

Pain may or may not be present at the onset depending verv largelv upon the 
amount of pressure exerted and not so much on the toxicitv but during the course 
of the disease it frequently manifests itself, often characterized bv its severity 
particularly in the fulminating type of the disease. 

Examination will frequently reveal infection and even free pus in the spheno¬ 
ethmoidal region but this is just as frequently absent as present. It is often possible 
to note pathological changes only after careful and minute examination with the 
naso-pharyngoscope and even then ofttimes but a hyperplastic condition of the 
sinus mucosa is discovered. It must be remembered that an advanced hyperplasia 

e ™“? ld Pr ° per may be present the slightest involvement of the 

middle turbinate, therefore, this structure should unhesitatingly be sacrificed in 
order to bring the spheno-ethmoidal region under observation. 


,, BeU > 9: H ". Case ?f bilateral papilledema due to empvema of sphenoid and 

ethmoid sinuses. Operation and recovery. Arch. Ophthalmol. July, 1918 567b. White- 

^ C y 7 Q°? 9;5 erent,al Diagnosis and Operative Technic. Laryngoscope^ 

August, 1921. j>67c. White: Retrobulbar neuritis from posterior accessory sinS 
? hm Y? nd Lan?g .Sept. 1919,p. 793. 567cLfail: MonocX/Retro- * 
bulbar Optic Neuritis from Hyperplasia of the Ethmoid Bone. Trans. Am. Acad of Ophthal- 

^^•? D fl 0t % La ^ :ng; r P - 431 ’ 1917 and 1918 - White: The Diagnorisand 

Prognosis of loss of vision from accessory sinus disease. Joum. Am. Med.; May 29, 1920 
r»6/f. Caldwell: Diseases of the pneumatic sinuses of the nose and their relation to certain 
affections of the eye. Medical Record, p. 1893. 567g. Schimer: Optic nerve affections 

due to ethmoiditis. Am. Med., p. 424,1910. 567h. Rislev: Optic neuritis associated with 

the . no ^- J oum- of Nervous and Mental Diseases, p. 270 
1909. »6/i. Stark. Retrobulbar Neuntis Secondary to Diseases of the Nasal Sinuses. Journ. 
A.M.A., vol. 77, No. 9, 1922. s67j. White: Aeration of the Posterior Accesson^ Sinuses in 
Acute optic neuritis. Laryng., p. 382, 1922 567k. Husik reports a remarkable case in a 

boy 7 years old who suddenly became totally blind. The sphenoids were immediately opened 
and vision returned to normal m a few weeks. Laryngoscope, p. 874, 1922. * 



400 


THE ACCESSORY SINUSES OF THE NOSE. 


Beginning pallor of tlie fundus or undue congestion constitutes an immediate 
indication for operative intervention for the purpose of relieving these conditions 
which of course are only fore-runners to the loss of sight. 

Treatment. These symptoms should be met with prompt and energetic treat¬ 
ment at their earliest onset. Every hour of delay will mean that much permanent 
diminution in the vision of the patient. 567d While improvement always follows the 
operation during the early stages, a certain amount of permanent impairment of the 
vision is always taking place during the progress of the process owing to the destruc¬ 
tion of the fibres of the optic nerve. The longer this process is permitted to con¬ 
tinue, just that much less vision we must expect after operation and full recovery 
of the patient. We are very much in the same position as we were with the frontal 
sinus. Just as removal of the anterior end of the middle turbinate was indicated 
to give operation and drainage, now we are called upon to remove those structures 
obstructing free access to the anterior sphenoidal wall, namely, the posterior end of 
the middle turbinate and the posterior ethmoid cells. In this way not only is the 
source of the infection reached but the bleeding incident to the operation depletes 
the neighboring parts and relieves the congestion and pressure around the 
optic nerve. 

In cases operated upon within three weeks, improvement can be confidently 
expected even up to normal vision; while those in which the operation is delayed 
beyond two months, the improvement is usually so slight as to be almost neglible. 5675 
The earlier the operation, the better the chance of return of vision to normal, and 
the earlier improvement should manifest itself and once having set in, may continue 
to show progress for months after the operation. 

To bear out the importance of early surgical interference, numerous cases of 
optic atrophy resulting from delayed surgical intervention in which the vision would 
have been saved have been recorded. 567e > 567f I do not know of a more insistent indi¬ 
cation for immediate operative interference than the appearance of an incipient 
retrobulbar neuritis. 

THROMBOSIS OF THE CAVERNOUS SINUS. 

On account of the normal anatomical position of this venous sinus against the 
lateral walls of the sphenoid cavities, the former may readily become infected through 
the bony walls, either by direct extension of the pathological process through the 
canaliculi (lymph) or by means of the perforating veinlets. The mucosa of the 
sinus may become loosened from the underlying bone and infection take place with¬ 
out the mucous membrane becoming much involved. 

Process of Infection-Mechanism ™ 8 —After the inflammatory process has pene¬ 
trated the sphenoidal walls, septic infiltration of the venous walls occurs with the 
production of an endophlebitis, which predisposes to coagulation of the blood along 
the line of inflammation. The clot formed by this coagulation accumulates layer by 
layer until the lumen of the vein at this point is partially or completely obliterated 
with a corresponding stagnation of the circulation. Pathological changes now take 
place in the thrombus. At first fibrous degeneration sets in with adherence to the 
walls of the vessel. If the infection is virulent the clot soon breaks down in a semi- 
purulent mass, at first in the centre, gradually spreading to the extremities. The 
thrombus being now soft and pliable, small portions are being continually thrown 

. . ^? 8 .* Sf- Cla ir Thomson: Cerebral and Ophthalmic Complications in Sphenoidal Sinus¬ 

itis. British Med. Journ., vol. 2, p. 768, 1906. 




SPHENOID SINUS. 


401 


off into the circulation at the distal end of the clot which cause thrombi in other 
veins. "V arious forms of meningitis, as well as brain abscess, metastatic abscess 
and infarcts in the lungs appear to be common sequelae of this affection when the 
patient’s life is prolonged. 

Symptoms. 569 — The onset is similar to that of meningitis: 
rapid pulse, profuse perspiration and pyaemic temperature. Pain 
is usually present, referable to the affected side of the head and 
behind the ear. Any form of cerebral symptoms may be present, 
from delirium to coma, although a condition of stupor from which 
the patient may be aroused seems to be the rule. 

Ophthalmic Manifestations .—These are always prominent, and by their early 
appearance (six to sixteen days after the onset) are almost characteristic of the 
affection. The first symptom to be noted is oedema of the lids and the lower part of 
the frontal region on the affected side, which gradually spreads until the opposite 
side is also involved. 

Exophthalmos gradually begins to make its appearance with impairment of the 
ocular movements. The visual changes do not appear to be characteristic, as there 
may be little or no impairment of sight, 570 or, on the other hand, intermediate stages 
to total blindness; 571 however, little reliance can be placed on these tests, as the 
mental condition of the patient is such as to preclude the possibility of obtaining 
satisfactory answers. 

The pupillary reactions become sluggish, and, if the patient continues to live, 
purulent infection with ulceration of the conjunctiva results. During these local 
changes aggravation of the general condition is occurring, which finally results in 
delirium, coma, and death. 

Meningitis .—This is even more frequently observed than throm¬ 
bosis as a complication of sinusitis. 571a The infection spreads 
directly by contiguity through the mucosa and bone to dura and 
meninges. It is often possible to determine maeroscopically that 
portion of the bony wall through which the infection found its 
passage. When the infection follows the course of the communi¬ 
cating venae perforantes causing a thrombo-phlebitis, pathological 
changes in the bony walls are not apparent. 

Dural Abscess. 

Circumscribed abscess of the dura due to sphenoiditis is ex¬ 
ceedingly rare as meningitis is the usual form of meningial compli- 

569. St. Clair Thomson: The Causes and Symptoms of Thrombosis of the Cavernous 
Sinus. The Ophthalmic Review, p 293, 1908. 570. Jessop: Infective Thrombosis Involv¬ 
ing Cavernous Sinus. Trans. Ophth. Soc., United Kingdom, vol. 23, p. 184, 1903. 571. 
Reber: Differential Diagnosis of the Orbital Conditions Caused by Sinusitis, Including the 
Report of a Case of Thrombosis of the Cavernous Sinus. Penna. Med. Joum., p. 790, 1910. 
571a. Leegaard: Intracranial Complications arising from the sinus Sphenoidalis. Anna. 
Otol., Rhin. and Laryng. March, p. 48, 1919. 571b. Brawley: Case of Subdural abscess Sec¬ 
ondary to Sphenoid Infection. Ann. Otol., Rhin. and Lary., p 788, Sept., 1921. 





402 


THE ACCESSORY SINUSES OF THE NOSE. 


cation. Even in the event of its presence in the diagnosis of 
abscess is rarely made except at the autopsy. One case, however, 
has been reported which was operated upon through the posterior 
sphenoidal wall intra-nasally with complete recovery. 571 * 

Treatment. 

It depends considerably upon what intranasal measures have 
been adopted to make the diagnosis as to what form of treatment 



Fig. 234.—Position of the hands of patient and surgeon in irrigating the sphenoid sinus. 

will be instituted; thus, if it has been necessary to resect a portion 
of the middle turbinate and enlarge the sphenoidal ostium before 
disease in this sinus was discovered, already the surgical end of the 
treatment will have been accomplished, and nothing remains, at 
least for the time being, by simple irrigation and perhaps the 
insufflation of some antiseptic powder. If on the other hand, had 
but a tentative diagnosis been made, during which time the aug¬ 
mentation of the symptoms became alarming, it is not only justi¬ 
fiable but absolutely indicated to institute at once such surgical 








SPHENOID SINUS. 


403 


procedures as will disclose the precise condition of the mucosa of 
the suspected cavities. 572 

Let us, however, take a case which by reason of sufficient width 
of the olfactory fissure we have been able to diagnose without 
removal of any portion of the nasal structures. TVe see the pus 
exuding from the spenoidal ostium. Our first thought is to intro¬ 
duce a catheter and irrigate the sinus, applying this principle daily 
until amelioration and subsequent cure results. 

Technic of Catheterization and Irrigation .—"When the middle 
turbinate has not been disturbed and the sphenoidal ostium re¬ 
mains invisible, it is absolutely essential, before attempting this 
manipulation, that the sound shall have, beyond doubt, penetrated 
into the sinus in order that one may have exact knowledge as to the 
direction, proper curve to the catheter, etc. The catheter is now 
bent in a curve corresponding to that of the sound and introduced 
in the same' manner until it penetrates the ostium. Holding it in 
place with the left hand, the syringe is filled with the right and 
given to the patient to hold while the nib on the end of the rubber 
tube is fitted into a catheter. (Fig. 234). These are then held 
together by the left hand, the syringe being taken into the right, 
and the patient lowers the head and gentle pressure is made upon 
the piston until the injected fluid issues from the nose. Pus does 
not usually escape at the first few drops, but appears after several 
drachms have escaped, depending upon the consistency of the 
secretion. It may even occasionally happen that none is observed, 
particularly when freely miscible with water, as it may lodge in 
the various interstices of the posterior ethmoid capsule; there¬ 
fore, this procedure cannot be considered as reliable a one as 
lavage of the maxillary sinus. Several ounces (8-12) of fluid 
should be injected, and preferably caught in a black hard-rubber 
pus basin, in order to more thoroughly differentiate the color of 
the returned liquid. 

This manipulation is not always unattended by danger, as 
svncope and unconsciousness 573 have been reported following 
simple irrigation; therefore, one must exercise great care to use 

572. Curtis: The Sphenoidal Sinus and its Surgical Relation. Laryn., p. 860, 1904. 
5 73. Schech: Zur Pathologie der Keilbeincaries. Verh. d. ver. Sudd. Lary., S. 198,1898. 




404 


THE ACCESSORY SINUSES OF THE NOSE. 


slight pressure, at least at the beginning/ 5 The therapeutic value 
of simple irrigation is doubtful except in acute cases, which, how¬ 
ever, are rarely recognized. The unfavorable situation of the 
ostium tends to allow the accumulation of a certain amount of 
residual pus which cannot he removed entirely without opening 
the drainage passages. This can he accomplished only by enlarg¬ 
ing the sinus ostium. 

According to our experience, amelioration usually occurs, but 
the cure remains unaccomplished. This is undoubtedly .due to the 
permanent changes which have taken place in the sinus mucosa. 
It is now clear that we cannot expect regeneration to follow the 
mere mechanical cleansing of the sinus. Something further must 



Fig. 235.—Farad’s bone-cutting forceps for enlarging the sphenoidal ostium. 


be done to facilitate better drainage and aeration of the cavity. 
This can be accomplished only by enlarging the normal ostium, a 
procedure which occupies but a few moments and is entirely free 
from pain. 

Technique of Enlarging the Normal Ostium . — Cocainize 
thoroughly the septum and septal side of middle turbinate, forcing 
back the cotton mop until the anterior sphenoidal wall is en¬ 
countered, using, if necessary, the long-bladed Killian speculum as 
an aid in reaching the deeper-lying portions. When these parts 
have lost their sensation, introduce the cotton well within the 
spheno-ethmoidal fissure and allow it to remain therein, thus 
anaesthetizing the anterior wall, especially around the ostium. 

Undoubtedly dehiscence of the walls was present in these cases, as we have never met 
with such symptoms in several hundred irrigations. 





SPHENOID SINUS. 


405 


During this manoeuvre it is wise to cause the patient to hold the head with 
the chin resting on the chest to prevent the cocaine solution from escaping back¬ 
ward into the nasopharynx and being swallowed. It is rather the systemic effect 
of the cocaine than the shock of the operation which causes syncope in patients 
while operating in this locality. 

After several minutes the cotton carrier is removed and another 
smaller one, wrapped tightly around the extremity, is dipped into 
adrenalin 1/1000 and gently forced within the ostium, using a 
screwing motion to facilitate its entrance. This is in a few moments 
again removed, and it will be noted that the calibre of the ostium 




Fig. 237.—Severing the middle turbinate in the 
centre prior to the removal of the posterior half. 


Fig. 236.—Enlarging the natural ostium of the 
sphenoid sinus without removal of middle or superior 
turbinate. 

is considerably enlarged. At this stage it is a comparatively 
simple matter to introduce the spear-shaped point of the cutting 
forceps (Fig. 235) and resect piecemeal the anterior wall in a 
downward (Fig. 236) direction until the opening is flush with the 
sinus floor. To guard against too early closure of the wound it is 
also advisable to remove a portion in the lateral direction. 

Some little practice will be necessary until one becomes entirely accustomed to 
these forceps, as the spring is so strong that during closure of the jaws, the 
shank has a tendency to jump, thereby disengaging itself from that portion to be 
removed. This can be overcome by holding the cutting portion firmly in place and 
pressing the handles together with a slow, steady motion. 


406 THE ACCESSORY SINUSES OF THE NOSE. 

This entire procedure should be accomplished without pain and 
with very little hemorrhage. The interior of the sinus is now 
cleansed by flushing and wiping with cotton, and the operation 
terminated by insufflation iodoform or a like dressing powder. 
The after-treatment consists of daily irrigation, followed by dry¬ 
ing and insufflation of powder until the discharge abates and 
finally ceases. In moderate cases this will usually suffice to bring 
about a cure, but occasionally this procedure will not give the 
desired space for complete drainage, when the radical operation 
with removal of all structures encroaching upon the anterior 
sphenoidal wall (posterior end of middle turbinate and superior 
turbinate) is indicated. 

It is the rule rather than the exception to find the olfactory 
space so narrow that it is impossible to reach all parts of the 
anterior sphenoidal wall even with a fine sound. This is due not 
only to the natural configuration of the parts, but, in the event 
of inflammation, to the various hyperplasias of the mucosa inci¬ 
dent thereto. Under such circumstances it is impossible to con¬ 
serve all of these anterior structures even in making a proper 
diagnosis, to say nothing of the conservative operation (removal 
of a portion of the sphenoidal wall). These conditions being 
present, we can only resort to the more extensive operative 
measure, i.e., the radical operation. 

Indications for the Radical Operation . 573a —It must not be con¬ 
sidered that the conservative operation has failed when a certain 
amount of discharge continues to be secreted. The main indication 
was to relieve the symptoms and dangers incident to the 
obstruction to free drainage, and when this has been accom¬ 
plished the most serious menace has been removed. On the other 
hand, the annoyance, and even harm, incident to the continual 
post-nasal discharge must not be minimized but, with the dis¬ 
tressing subjective symptoms a thing of the past and with a free 
opening in the sinus wall, we are in a much better position to deal 
with the secreting mucosa than under the former conditions. The 
instillation of a few drops of 5 per cent, solution of nitrate of 
silver or a weak solution of zinc chloride will often yield brilliant 
results in these cases. 

573a. Skillern: Sphenoid Sinus. Present Day Value of Surgical Procedure. Journ 
Am. Med. Assn., Dec. 23, 1916. 




SPHENOID SINUS. 


407 


1. In all cases of threatened complications. 

In acute, and particularly in chronic, cases with insufficient 
drainage cerebral or orbital complications are liable to occur at 
a moment’s notice. At the first warning of these the radical 
operation should be performed without a moment’s delay, as 
many cases can be saved where procrastination would cause per¬ 
manent injuries, and even death. 574,575 

That this applies also to orbital and ophthalmic complications has been well 
shown by Holmes 576 and Coppez, 577 who, by curettage of the ethmoid and sphenoid, 
was able to restore sight in two cases in which blindness had resulted from 
the sinusitis. 

2. When acute exacerbations frequently occur. 

There is no question that the sphenoid mucosa, after once being 
the seat of an inflammatory process, even after complete recovery, 
exhibits a marked tendency toward renewed inflammation with 
every slight change in the nasal mucosa. When these exacer¬ 
bations become so frequent as to be the source of almost constant 
annoyance to the patient, and, considering the rapid tendency of 
the opening to close through excessive granulation, an enlargement 
of the opening by means of the radical operation is indicated. 

3. Upon the occurrence of ocular manifestations. 

One of the most important symptoms associated with chronic 
sphenoidal empyema is a gradual diminution in the field of vision. 
While this is often dependent upon stagnation or special virulence 
of the secretion, such is not always the case, as the inflammation 
in the sphenoid need not necessarily be purulent in order that 
orbital complications occur; a rarefying ostitis can also cause 
infection of the optic nerve. 

4. Pulsating Sphenoiditis. 577a 

It has been shown that the presence of pulsations in the 
secretion are transmitted from the mucosa which in turn receives 
the impulses from the internal carotid situated within the 
cavernous sinuses. This is proof positive of an especial thinness 


574. Snellen, Quix: Bericht. d. Niederl. phys. u. mediz. Kongress, Utrecht, 1909. 
575 Kander: (Meningitis beim Kielbeinhohlenempyem mit Ausgang in Heilung, Verh. sud- 
deiitsch. Lary., S. 109,1907.) This case, which has been reported in extenso, illustrates well 
the value of early surgical intervention. See also R. H. Skillern: The Importance of Rhino- 
logical Examination in all Cases of Meningitis of Doubtful Origin. Penna Med. Journ., 
Aue 1909 576. Holmes: The Sphenoidal Cavity and its Relation to the eye. (Case 1.) 

Archives of Ophthal., vol. 25, p. 460,1896. 577. Coppez: .Deux cas de eccite par smusite 
sphenoidale. La Presse Med. Beige., No. 11, p. 528, 1906. 577a. Pollock: Pulsating Sphe- 
noiditis. Annals of Otol., Rhin. and Lary., p. 744, Sept., 1921. 




408 


THE ACCESSORY SINUSES OF THE NOSE. 


of the lateral bony wall and experience has shown that the infec¬ 
tion in these cases is particularly difficult to eradicate being very 
resistant to treatment. It is wise to remove as much of the 
anterior wall as possible thus obtaining the greatest possible 
drainage and aeration but under no circumstances to curette the 
lateral wall as is obvious under such conditions. 

Radical Operation of Sphenoid. 578 ' 589 —1. Cocainize the entire 
side of the nose to be operated on with 20 per cent, cocaine-adrenalin 
solution until tactile sensation is entirely lost. 



Fig. 238.—Radical intranasal operation on Fig. 239.—Radical intranasal operation on 

sphenoid. Removing posterior half of middle tur- sphenoid. Hajek’s hook in position for breaking 
binate with the snare. down the superior turbinate. 


2. Endeavor to sound sinus and get general bearing with probe. 

(Fig. 232.) (a) See how much of anterior wall of sphenoid can be 

reached with point of probe, (b) Approximate the depth of the 
spheno-ethmoidal recess, (c) Whether posterior deviation or 
thickening of the septum exists which might interfere with opera¬ 
tion. ( d) Whether polypi or polypoid tissue is present. (This 
is important on account of the bleeding which will tend to obscure 
the field, once the operation is started.) 

3. Introduce scissors over the centre of the middle turbinate 
and press firmly into place so that the entire dependent portion 
will be severed in one cut. (Fig. 237.) 


578. Hajek: Zur diagnose u. intra-nasalen chirurg. Behandl. d. Eiterung d. Kiel- 
beinhohle,etc. Arch. f. Lary.. Bd. 16, S. 105, 1904. 579. Laurens: Chirurgie du Sphenoide 

Archiv. Internat. de Laryn., T. 17, p. 81, 1904. 580. Skillern: The Present Status of the 
Radical Operation on the Sphenoid Sinus. Journ. Am. Med. Assn., Dec., 1908. 



SPHENOID SINUS. 


409 


4. Sever turbinate with one firm cut. (The bleeding after this 
is usually fight and can be completely controlled by the applica¬ 
tion of adrenalin chloride 1/1000 on cotton pledgets.) 

5. Pass snare around posterior fragment, working the end of 
the instrument well up into the cut, and remove that portion. 
(Fig. 238.) (The hemorrhage here will be more profuse, owing 
to the spheno-palatine artery being severed close to its entrance 
into the nose. The patient should have experienced no pain thus 
far; the only annoyance is purely psychical, due to the sound of 



Fig. 240.—Radical intranasal operation on 
sphenoid. Removing the debris with the Grun- 
wald forceps. 



Fig. 241 .—Radical intranasal operation on 
sphenoid. The evulsor introduced closed into the 
sinus. 


crunching which is caused by the breaking down of the eth- 


moidal cells. 

6. Pass Hajek’s hook, point downward, along the oltactory 
fissure until it meets the anterior superior wall of the sphenoid 
sinus, and turn point forward and outward toward eye, thus bury¬ 
ing it in the posterior ethmoidal labyrinth (Fig. 239), and draw 
fi rm ly toward the nasal outlet, thereby opening these cells in their 
entirety from above downward. 


One need have no apprehension of injuring the orbit by this procedure, f°r the 
posterior ethmoid labyrinth is always thicker than the length of the hook, and if by 
chance dehiscence of the lamina papyracea was present the orbital fat, being one- 
half inch thick, would protect the orbital contents from serious injury. 

The posterior portion of the nasal roof behind the lamina crib- 
rosa varies from 1 mm. to 2.5 mm. in thickness, which precludes 
the possibility of injury by the back of the hook in this direction. 



410 THE ACCESSORY SINUSES OF THE NOSE. 1 

(. This procedure should be repeated several times until the 
entire posterior labyrinth is reduced to shreds. 

8. The fragments are now removed by grasping and pulling 
out with a Griinwald forceps, not fenestrated. (Fig. 240.) The 
object of this is twofold: 1. By grasping and pulling out, much 
larger pieces are removed than by cutting. 2. The length of the 
operation is materially shortened. 

Bleeding is now more or less profuse, but is usually controlled with the 
adrenalin tampons. In rare cases, however, the operation must be suspended at 
this point to be finished at a later date. The pain may also be severe, especially 
when the fragments which contain the naso-palatine nerve are grasped and torn out. 

The anterior wall of the sphenoid is now in plain view, although 
so covered with blood that the ostium, unless large or exuding pus 
cannot readily be found. This must be sought for with the probe. 

An anatomical condition which is frequently present may now be the source 
of much confusion, causing one to believe that the sphenoid sinus has already been 
opened and is now presenting its posterior white shining wall, i.e., when the 
posterior cell of the posterior ethmoid labyrinth forms the greater part of the 
anterior sphenoidal wall (see Fig. 182). Sometimes the pars nasalis is so narrow 
that this cell seems to occupy the entire posterior inferior portion of the nasal 
cavity, the sound only penetrating to its posterior wall. This error may be dis¬ 
covered in two ways: 1. By careful palpation with the sound one feels that there 
is a ridge between the septum and the sinus cavity, in other words, the sound does 
not glide off gently from the septum into the sinus, but meets with a narrow 
cleft. 2. By measuring the greatest depth of the supposed sinus one will find it 
only reaches as far as the normal measurement to the anterior sphenoidal wall. 

9. The sphenoidal ostium is now penetrated with the double 
evulsor (Fig. 241), the blades opening apart (Fig. 242) and the 
instrument, withdrawn (Fig. 243), this being done several times, 
b\ cutting in different directions until the hole is made as large as 
possible with this instrument. 

The size of the opening obtained depends upon the thickness, shape and 
condition of the anterior wall. Naturally one could not expect to obtain as large 
an opening in Fig 225a as in Fig. 225c. 

If the ostium is not visible and cannot be found with the probe, 
several procedures are at the command of the operator: 

(1) Breaking through with Shaeffer’s or Hajek’s curette or 
Andrew’s knife. 

(2) Boring a small opening with a hand drill. 

(3) Using an electric trephine (not recommended). 

(4) Using Gmeinder’s chisel (not recommended). 

10. Enlarge the opening as far as possible in all directions 
with the sphenoid forceps.. (Fig. 244.) This is, perhaps, the 
most important and most difficult step in the operation, so far as 


SPHENOID SINUS. 


411 


a permanent cure is concerned—most important because the larger 
the hole the better the drainage, and most difficult because the 
more one bites away, the thicker the bone becomes. (Fig. 245.) 
If possible, the entire floor should be removed, thus obliterating 
the sinus, as it is almost 
incredible the celebrity with 
which a hole as large as the 
end of one’s thumb after a few 
weeks will close up to the size 
of a small pea. One need have 
but little fear of extraordi¬ 
nary hemorrhage here, as 
there is no artery of impor¬ 
tance to be injured; in fact, 

Zuckerkandl states that the 
sphenoidal is the smallest 
branch of all the turbinal 
arteries. (Plate I.) 

This stage of the operation 
is the most trying for the 
patient, as there is always 
more or less pain connected 
with the bone-biting process. If the patient shows a tendency to 
syncope, he should be allowed to he down for several minutes, 
after which the operation can be finished without applying 
more cocaine. 



11. Insufflate powder and unless bleeding avoid packing 
with gauze. 

Shall we curette the sinus ? Personally, I am opposed to this, 
for several reasons. 1. The danger of wounding neighboring 



Fig. 242.—Radical intranasal ope-ation on 
sphenoid. The blades of the evulsor sprung apart 
ready to be withdrawn. 










41-2 THE ACCESSORY SINUSES OF THE NOSE. 

structures with fatal consequences. 581 The cavernous sinus is most 
to be feared, as it lies against the lateral walls of the sphenoid sinus. 
(Fig. 33.) Dehiscence frequently occurs here, so that the operator 
may have only the thickness of the mucous membrane and venous 
wall between him and practically instant death. 2. The mucous 
membrane of the sinus is rarely so diseased and degenerated as 


to even require partial removal. E 
though it be so oedematous as to fill 
entire cavity like a baggy mass, it is sur¬ 
prising how quickly regeneration occurs 
after opening the sinus. Scarification or 
the application of a 20 per cent, zinc 
chloride or 1-5 per cent. AgN0 3 solution 
will often hasten this resolution. Polyps 
of this sinus resulting from empyema 
seem to me so rarely met with that they 
demand little consideration. 

After-Treatment. —Do not treat the 
nose for four or five days, unless one or 
more of the following symptoms occur: 

(1) post-operative bleeding; (2) chills, 
fever, and symptoms of pus retention; 

(3) inordinate headache over vertex Fl °- 244 _ nofi e forcSs dified8phe " 
in occiput. 

After the fourth or fifth day, in the vast majority of cases, one 
will note that the swelling of the mucous membrane has subsided; 
our most important steps now are to cleanse the sinus and to prevent 
the opening in the anterior wall from gradually growing smaller. 

I have discontinued the packing with iodoform gauze as in a 
number of cases cerebral symptoms developed which were most 
alarming and only disappeared after removal of the gauze. 

The reason this wall shows such a tendency to renew itself is easily explained 
when one takes into consideration the method nature adopts to bring about healing. 
In regeneration of the mucous membrane the deeper layer of epithelium is 
lormed from the periosteum and bone, the superficial layer from the mucous 
membrane of sinuses and nasal cavity. When the bone is wounded, the granula- 
tions springing up from the bone are so luxurious that the lateral growths from 

R f P ° rt of a Fatal Operative Case Showing Absence of the Outer 
Sphenoidal Wall, etc. Laryngoscope, p. 43, 1909. 















SPHENOID SINUS. 


41S 


the mucous membrane of the sinus and nose cannot grow fast enough to form a 
covering for the former (bone), and complete healing only occurs when this 
continuity of membrane takes place. This condition we attempt to further by 
periodic cauterization of the edges with chromic acid or nitrate of silver. About ten 
days after the operation, when the parts have fully recovered from the post-operative 
swelling, a bead of chromic acid, fused on the end of a long probe, is carried back to 
the opening in the sinus and the edges thoroughly cauterized. This should be con¬ 
tinued every week until the edges are covered with scar tissue, which prevents 
further closure of the sinus. 

In applying either chromic acid or nitrate of silver, care must be taken that 
the part is thoroughly dry so that the substance will not run. It is also of impor¬ 
tance not to touch any part of the nose with the acid while the probe is being intro¬ 
duced, as sometimes severe reaction follows which materially interferes with the 
resolution of the part. 

Halle’s Operation. 581 * —1. If the nasal septum interferes with a 
free passage to the anterior sphenoidal wall, a submucous resection 
will be necessary. 

2. The middle turbinate is forcibly dislocated against the lateral 
nasal w T alls by means of any suitable instrument. 

3. A cross incision is made through the mucosa and periosteum 
of the anterior sphenoidal wall, having for its centrum the sphe¬ 
noidal ostium. 

4. The four mucoperiosteal flaps are now elevated from the bone 
of the anterior wall as far as possible. 

5. The smallest burr is now used to enlarge the ostium to a 
dimension that will permit the employment of the pear-shaped burr. 

6. The large, pear-shaped burr is now used on every portion of 
the anterior wall until the structure has been removed. No fear 
need be entertained of injury to the internal walls of the sinus, as 
the burr has a smooth extremity. 

7. The mucoperiosteal flaps are packed into the cavity and there 
retained by tightly packed gauze. 

ULTIMATE CONDITION OF THE OPERATED SINUS. 

With practically all the anterior wall removed, even though 
a certain amount of closure through granulation takes place, should 
reinfection occur no great damming back of the secretion is possible. 
On this account the old symptoms caused by retention and stagna¬ 
tion of the secretion do not return. The flow of secretion becomes 
thinner and thinner until it finally ceases. This cessation is not 
permanent, for the mucosa shows a great tendency to become rein¬ 
fected vdth renewal of the secretion during every succ eeding attack 

581a. FTalleUDie" Intranasalen Operationen bei eitrigen Erkrankungen der Neben- 
hohlen der Nase. Arceiv. f. Laryng., Bd. 29, H. 1, S. 105, 1914. 





414 


THE ACCESSORY SINUSES OF THE NOSE. 


of acute coryza. However, with the subsidence of the cold the dis¬ 
charge from the sinus gradually ceases until it disappears spontane¬ 
ously, to reoccur at the next attack. This condition may continue 
for years without apparently causing great annoyance or injury to 
the general health of the patient. If, on the other hand, the dis¬ 
charge becomes thick, granular, or foetid, it will be necessary to 
enlarge the opening and apply cotton pledgets saturated with a 10 
to 20 per cent, nitrate of silver solution directly to the diseased 
mucosa, allowing them to remain there five minutes. This treat¬ 
ment, continued every other day for ten days, will speedily bring 
about a cessation of the discharge. 

Maxillary Route . 582 —By this method the sphenoid sinus is 
reached through a large opening made in the anterior wall of 

the maxillary sinus. This is 
Jansen’s method, although 
Furet 583 has so modified it that 
the ethmoid cells are spared. 

Jansen’s Method. 58 *~ 585 —1. In¬ 
cision in gingivo-buccal fold as 
for Caldwell-Luc operation. 

2. Removal of entire anterior 
wall. 

3. The posterior wall is 
broken into at its superior por¬ 
tion, thereby exposing the pos¬ 
terior ethmoidal cells. 

The posterior ethmoid 
cells are removed, thus bringing 
into view the anterior wall of 
sphenoid. 

5. Removal of the entire anterior sphenoidal wall. 

The indications for this operation, as given by Laurens, are: 

1. When the nasal route is difficult or impossible, even though 
the maxillary sinus is not diseased. 

2. When maxillary sinusitis complicates the sphenoidal 
affection. 

582 Jansen: Zur Eroffnung der Nebenhohlen der Nase bei chronischer Eiterung. Arch, 
f. Larv., Bd. 1,1894. 583. Furet: Trepanation des deux sinus sphenoidauxa bravers un sinus 
maxillaire sain. Presse Medicale, p. 61, 1901. 584. Mosher: The Anatomy of the Sphe¬ 
noidal Sinus and the Method of Approaching it from the Antrum. Laryngoscope, p. 177, 1903. 
585. Berens: Fourteen Cases of Chronic Multiple Sinusitis Operated upon by Way of Max¬ 
illary Route. Trans. Am. Lary., Rhin. and Otol. Soc., p. 89, 1904. 



Fig. 245.—Radical intranasal operation 
sphenoid. Hajek’s modified forceps introduced and 
ready to remove the thick osseous base of the ante¬ 
rior wall. 



SPHENOID SINUS 


415 



Fi«. 246.—Relation of an unusually large sphenoid sinus to the maxillary antrum. Dotted line shows 

extent of sphenoid sinus. 


Maxillary sinus 


Area of sphenoid 
sinus 



Ftg 247 —Relation of a small sphenoid sinus to the maxillary antrum. Dotted line shows the extent of 
' the sphenoid sinus. 









416 


THE ACCESSORY SINUSES OF THE NOSE. 


3. When cerebral complications of sphenoidal origin appear. 

This method has certain well-defined disadvantages : 586 

1. A healthy sinus is needlessly opened and exposed to infection. 

2. In spite of the utmost care, there is danger of wounding 
structures situated in the pterygo-palatine fossa and causing pro¬ 
fuse hemorrhage and subsequent disturbance of the sensibility of 
the face, to say nothing of fatal consequences. 

3. Danger of wounding the optic nerve. 

Sieur and Jacobs, while practising this operation on the 
cadaver, perforated the internal wall of the orbit immediately 
below the groove of the optic nerve, which was dangerously near 
the nerve and accompanying vessels. In other instances perfora¬ 
tion of the sella turcica immediately behind the optic groove and 
fracture of the external nasal wall in the superior meatus occurred. 
The favorable anatomical formation for this operation is shown in 
Fig. 246, while unfavorably in Fig. 247. Weighing the advantages 
and disadvantages, it would appear that, in the main, the opera¬ 
tion is not advisable. The only indication that is debatable is 
when disease co-exists in the maxillary and sphenoid sinuses. 

cv , i 58<S * ? nodi: 4 Da , s Yerhaltness Kieferhohle zur Keilbeinhohle und zu deren vorderen 
Siebbeinzellen. Arch. f. Lary, Bd. 11, S. 391, 1901. 






PART VI 

COMBINED EMPYEMA, OR MULTIPLE SINUSITIS. 

PANSINUSITIS. 

COMBINED EMPYEMA OR MULTIPLE SINUSITIS. 

These synonymous terms are applied when two or more sinuses 
of one or both sides are simultaneously diseased. 

While in fulminating cases this condition may have been multiple 
from its inception, nevertheless in the vast majority of instances 
one sinus has been the original focus of infection. Certain com¬ 
binations are practically always present: thus in frontal sinusitis 
the anterior ethmoid cells are frequently involved; frontal with 
maxillary sinusitis, as sphenoid with posterior ethmoid, are not 
uncommon combinations. It is, however, rare to meet one sinus 
belonging to the anterior series and one belonging to the posterior 
simultaneously involved, with the possible exception of the antrum 
and sphenoid. The occasional intimate anatomic relationship of 
these two (see Fig. 246) would account for this combination, al¬ 
though, despite this fact, its actual occurrence is much less frequent 

than one would naturally suppose. 

When two sinuses are diseased one usually shows further ad¬ 
vanced pathological changes and is more resistant to treatment than 
the other. This one is the first affected, regardless of its position. 
Thus if the original focus of infection is in the frontal sinus, and 
the antrum becomes subsequently infected, one or two irrigations 
will completely clear up the latter, while the condition of the frontal, 
even after all intranasal procedures had been applied, may require 

an external operation to bring about an absolute cure. 

The opposite also holds as quite true; that is, a frontal sinusitis 
depending upon a preexisting maxillary infection will often clear 
up without further treatment after the maxillary disease has been 
eradicated. 

The question as to the possibility of a maxillary sinus empyema causing the 
mucosa of the frontal sinus to become infected has now been definitely established. 
It has been contended that on account of the high position of the frontal ostium and 
the inability of the purulent material to run up hill, infection from this source would 
h* i^nossible We must, however, recollect that an individual is not always m the 
erect position, and during reclining and sleep the frontal and the max. Iary ostiuin 
may be on the same level, and, even though a direct communication between 


f 


418 THE ACCESSORY SINUSES OF THE NOSE. 

sinuses did not exist, the constant bathing of the mucosa of the hiatus semilunaris 
(which is continuous with both sinuses) with infectious secretion could and does set 
up an inflammation which, spreading by continuity, sooner or later reaches the lin¬ 
ing membrane of the frontal sinus. 

It depends almost entirely upon the configuration of the maxillary ostium, 
hiatus semilunaris, and frontal ostium whether or how soon this secondary infection 
occurs, as it is far less frequent than maxillary sinus involvement depending upon 
frontal sinusitis. 

The symptoms of a combined empyema in which one sinus was 
first involved rarely exceed in severity those that accompanied the 
primary infection. The signs and complaints usually point toward 
the sinus which was the seat of the primary involvement, with the 
possible exception of maxillary sinusitis, in which the symptoms 
from the onset often simulate frontal disease. 

The diagnosis will be difficult unless one carefully examines each 
sinus individually. The symptoms from one sinus are so apt to 
completely overshadow the other that combined sinus, affection is 
not suspected, and the examiner is often well enough satisfied when 
he finds one cavity secreting purulent material without delving into 
the possibilities of other sources from which this discharge could 
come. The guiding principle is that one given on page 73, under 
“Diagnosis.” Follow up each sinus step by step in methodical 
order, rather proving the non-existence of disease in every sus¬ 
pected sinus than, on finding unmistakable evidences of pus in one 
particular cavity, to rest content and consider the diagnosis made. 

Treatment .—This should always be directed against the original 
source of infection when it is clear which sinus was primarily in¬ 
volved. Thus with frontomaxillary empyema depending upon the 
antrum, this cavity should first demand our attention, the treat¬ 
ment ranging from ordinary irrigations to a radical operation, 
depending upon the indications and severity of the case. The 
frontal condition will often spontaneously heal; thus by removing 
the cause the effect will often disappear of itself. This holds good 
for frontomaxillary or fronto-ethmoidal empyema depending upon 
the frontal sinus. In the ethmoidal region, however, it may be 
necessary to remove polypoid hypertrophies which may remain 
long after the frontal suppuration has ceased, even though they 
owed their origin to this source. When the disease appears to be 
of equal intensity in two sinuses, and it is found necessary to oper¬ 
ate, which one shall first demand surgical intervention? The best 
possible answer to this question is that both sinuses should be 
operated upon at the same sitting. In many combinations of sinus 


COMBINED EMPYEMA. 


419 


disease this will be merely a step of one operation, as in combined 
frontal and ethmoidal suppuration the partial removal of the an¬ 
terior ethmoid cells is hut an integral portion of the intranasal 
operation on the frontal sinus. The same may be said of the 
posterior ethmoid cells in the radical intranasal operation on the 
sphenoid sinus. Suppose, however, the frontal, together with the 
maxillary, is diseased. If the operation is to he endonasal, two 
procedures will he necessary—one on the frontal sinus, the other on 
the antrum. Suppose, however, for various reasons, it has been 
decided to operate on hut one sinus, which one shall be attacked and 
what shall be done with the other? The primary object of every 
operation is either to save life or to relieve suffering. If the first 
exigency was indicated during a sinus disease we would probably 
not consider either an intranasal procedure or the number of sinuses 
to be operated upon, hut rather perform an external operation to 
whatever extent deemed necessary, as we would then be dealing with 
a matter of life and death. This, however, is the exception rather 
than the rule, and the second condition, or that to relieve suffering, 
is the proposition that more often confronts us. I, therefore, in com¬ 
bined empyema always operate on that sinus which apparently is 
causing the most suffering, either from pain, secretion, or mechani¬ 
cal disturbances (engorgement of nose, crust formation, etc.), and 
at the same time endeavor to secure better drainage for the other. 
In this way a cure is often obtained without a subsequent operation, 
the second sinus healing sui generis . 

Thus in chronic frontomaxillary empyema, which probably had 
its origin in the frontal sinus with supra-orbital headaches, frontal 
tenderness, and discharge of foetid pus, with more or less occlusion 
of the nares on the affected side, I remove the anterior end of the 
middle turbinate and enlarge the frontal passages with the rasp, 
destroying all anterior ethmoid cells which would interfere with 
subsequent drainage. The maxillary sinus is either broken into 
with the Welhelminski trocar through the inferior nasal passage 
or more often simply irrigated by means of a Lichtwitz needle intro¬ 
duced through the same place. The after-treatment consists simply 
in keeping that side of the nose free with normal saline douches and 
frequent needle punctures and lavages of the antrum. If improve¬ 
ment in this cavity (antrum) is not observed within ten days, it is 
opened as soon as the postoperative swelling will permit. 

In frontomaxillary suppuration of dental origin it is necessary 
to adopt a different procedure. Here the offending tooth must first 




420 


THE ACCESSORY SINUSES OF THE NOSE. 


be removed. Suppose this has been accomplished but the patho¬ 
logical process had continued—pain in the alveolus on the affected 
side, profuse purulent discharge, almost complete nasal obstruction, 
and more or less frontal headache. Here it will be necessary to first 
attack the kntrum. The best intranasal operation at our command 
is the preturbinal method, therefore this is carried out, and after 
irrigation the interior of the sinus is carefully inspected with the 
nasopharyngoscope. If advanced pathological changes have oc¬ 
curred in the mucosa, particularly on the floor near the apices of 
the roots of the teeth, the curette is vigorously used until the dis¬ 
eased area is obliterated. After irrigation the cavity is loosely 
packed with one-half or one-inch seamed iodoform gauze. In order 
to facilitate regeneration of the frontal sinus the anterior third of 
the middle turbinate is now removed and any enlarged anterior 
ethmoid cells opened. The after-treatment is largely directed to¬ 
ward the maxillary sinus, and consists principally in changing the 
gauze every day or two, depending upon the profuseness of the 
secretion. The frontal sinus is carefully watched, and if it still con¬ 
tinues to secrete in undiminished quantity after the postoperative 
swelling has disappeared, the drainage passages can easily be en¬ 
larged with the graduated Sullivan rasps and irrigation practised 
until the purulent secretion ceases. 

Maxillary and sphenoid sinus empyema is a rare combination, 
and when present will require a double operation—one on the 
maxillary and one on the sphenoid sinus—provided the endonasal 
route be chosen. The external maxillary route for both sinuses is 
not to be recommended (see page 403). Posterior ethmoid and 
sphenoid disease is rather a rule when one of these structures is 
affected. As exenteration of the posterior ethmoid cells is but an 
integral part of the endonasal radical operation on the sphenoid, 
and while operating on the posterior ethmoid cells the sphenoid is 
usually, intentionally or unintentionally, opened, it will be seen that 
these structures are so intimately associated with one another that 
surgical intervention upon one will usually embrace the other. 
(See “Diagnosis of Sinuses,’’ 2d series.) 

When two sinuses of opposite sides are affected, such as a double 
frontal sinusitis, the indications are usually clear; i.e., an external 
radical operation. In the vast majority of instances the double 
condition is due to a perforation of the septum dividing the sinuses 
by the pathologic process, and the condition is so far advanced at 
the time it comes under observation that an external operation is 


COMBINED EMPYEMA. 421 

demanded. In this instance both sinuses should be attacked at the 
one operation. 

The same can be said when the frontal sinus and antrum on 
opposite sides are diseased. Both sinuses should be operated upon 
at the one intervention whenever practical, as it is as unwise as it is 
useless to subject the patient to the unnecessary suffering’ which a 
second operation would entail. 

PAXSINUSITIS. 

By this term is implied a general inflammation involving all of 
the sinuses of one or both sides. While pansinusitis of one side is 
uncommonly met with, that where all the sinuses are simultaneously 
involved belongs to the greatest rarity. This affection is more 
often dependent on a purulent inflammation of the bone and spreads 
by continuity, thereby assuming the characteristics of the latter 
lather than those of a sinus affection in which only the mucosa or 
lining membrane is involved. In all probability the inflammation 
starts in the mucous membrane (and possibly bone) of one sinus, 
and, either through excessive virulence or a debilitated general 
condition, or both, spreads on all sides to the bone and to neigh¬ 
boring sinuses. Sinusitis following scarlet fever is a striking ex¬ 
ample of this process. This affection shows jel peculiar tendency 
towards necrosis, and on this account has been termed “ Pansinu¬ 
sitis necrotia . 9 7 









INDEX 


A 

Abscess of brain, 146, 230, 261 
Abscess and fistula formation on face, 96 
Absence of frontal sinus, 201 
of sphenoidal sinus, 369 
Accessory ostium of maxillary sinus, 9, 112 
Acute inflammation of ethmoid sinus, 325 
of frontal sinus, 216 
of maxillary sinus, 143 
of sphenoid sinus, 378 
^Etiology of accessory sinus disease, 34 
Agger nasi, 3 
Alexander’s chisel, 289 
Alveolus, 109 

relation of, to roots of teeth, 109, 110 
Anatomy of the lateral wall of the nose, 3 
of the nose in frontal section, 13 
Anosmia as a symptom, 68 
Antrum of Highmore (see Maxillary sinus) 
Articulation of inferior turbinate, 5 
Asthma in sinus disease, 70 

B 

Bacillus of influenza, 30, 31 
Bacteria in sinus disease, 29 
Bacteriology of the accessory sinuses, 28 
Basic structure of the lateral nasal wall, 4 
Beck’s osteoplastic resection of frontal 
sinus, 295 

Blodd- and lymph-channels, extension of 
inflammation through, 41 
Blood supply of lateral nasal wall, 21 
Bronchial symptoms, 70 
Bulla ethmoidalis, 7 
cells of, 311 

circumscribed empyema of, 341 
displacement of, 316 
excessive size, 307 
under-development, 308 
frontalis, 212 

formation of, 212 
lamella, 308 

anomalies of 316, 

C 

Cacosmia as a symptom, 62 
Calcareous formation, 53 
Caldwell-Luc operation, 190 
Canine fossa, 108 

operation through, 190 
Cannula bent for frontal sinus, 248 
for maxillary sinus, 167 
for sphenoid sinus, 393 
Carcinoma, 53 
Caries of sinus walls, 227 
Catheterization of frontal sinus, 248 
of maxillary sinus, 167 
of sphenoid sinus, 392 


Cerebral complications', 101 
Children, empyema in, 101 
sinusitis in, 101 
Cholesteatoma formation, 53 
C lironic inflammation of the ethmoid sinus, 
328, 335 

of the frontal sinus, 237 
of the maxillary sinus, 147 
of the sphenoid sinus, 380 
Chronicity, cause of, 43 
Circulatory disturbances, 72 
C itelli’s method of operating on frontal 
sinus, 296 

Closed empyema, 140 
Combined empyema, 417 
Complications of sinus disease, 50, 91 
causes of, 93 
manner of occurrence, 94 
Contamination from an overlying sinus, 43 
Cowper’s method of opening the maxillary 
sinus, 126, 138, 178 
Cribriform plate, 2 
Crista galli, 14 

lachrymalis, 10 

Czerney’s osteoplastic resection on the 
frontal sinus, 293 

D 

Dahmer’s intranasal method of opening the 
maxillary sinus, 183 
Dehiscence in the sinus walls, 93 
Denker’s external method of opening the 
maxillary sinus, 196 

Dental caries as a cause of inflammation, 
125 

Dentigerous cysts, 131 
Depression in sinus affections, 73 
Development of the sinus, 22 
rationale of, 24 
of the ethmoid labyrinth, 23 
of the frontal sinus, 23 
of the maxillary sinus, 22 
of the sphenoidal sinus, 23 
Diagnosis of sinus inflammation, first 
series, 73 
second series, 76 
by suction, 84 
by transillumination, 78 
by tuning fork, 85 
by X-ray, 81 

Dilatation of sinus walls by internal pres¬ 
sure, 51 

Diphtheria as an setiological factor, 31 
Diplopia or double vision, 300 
Displacement of eyeball, 331 

photograph of, 259, 347 
Distribution of trigeminus nerve, 56 
Dizziness, 70 

Ductus nasofrontalis, 206, 207, 308 

423 







424 


INDEX 


E 


Eczema of face in sinus suppuration, 67, 
225 

Empyema of ethmoid cells, 326, 335 
of bulla ethmoidalis, 342 
of frontal sinus, 219, 237 
of maxillary sinus, 143, 147 
of middle turbinate, 341 
of sphenoid sinus, 394 
combined, first series, 73 
second series, 76 

Enlargement of the blind spot, 98, 100 

Erysipelas as a cause of inflammation, 30, 
67 

Ethmoid bone, 13 

boundaries, 16 
bulla of, 7, 120 
cribriform plate of, 17 
cells, 309 
labyrinth, 305 

anomalies of, 313 
anatomy of, 305 
anterior group of cells, 310 
Ballenger’s operation on, 334 
blood supply of, 322 
capacity of, 310 
compared to a box, 306 
complications following operation 
on, 355 

contraction of, 310 
dehiscences in, 322 
exenteration of, 350 
extension of, 310 
external operation on, 356 
general polypoid inflammation of, 
328 


Guisez’s operation on, 357 
Hajek’s method for removing pos¬ 
terior, 355 

infundibular cells, 312 
intranasal method of operating on, 
350 

lamella 
of bulla, 308 
of middle turbinate, 308 
of superior turbinate, 309 
of uncinate process, 307 
latent empyema of, 340 
Luc’s method of operating on, 353 
Mosher’s method, 353 
mucocele of, 342 
mucosa of, 322 
number of cells in, 309 
ostium, 310 
physiology of, 324 
posterior group of cells, 311 
projection of, 310 
pyocele of, 341 

differential diagnosis from muco¬ 
cele, 344 

relation of, to frontal sinus, 313 
to lateral nasal wall, 305 
of posteiior cells to optic nerve, 
323 


venous anastomoses, 322 
untoward symptoms following ex¬ 
ternal operation, 360 


Ethmoiditis, acute catarrhal, 320 
purulent, 326 
aetiology of, 325 
chronic, 328 
hyperplastic, 328 
suppurative, 335 
auto-vaccine in, 350 
Ballenger’s intranasal method for, 334 
cerebral complications of, 348 
chronic inflammation, 328 
suppurative, 328 
classification of, 328 
complications of, 345 
diagnosis of acute, 327 
of chronic, 331, 361 
differential diagnosis, 336, 340, 344 
Guisez’s external operation for, 357 
hyperplastic, 328 

with suppuration, 344 
intracranial complications of, 348 
latent empyema, 340 
Luc’s operation in, 353 
Mosher’s method, 353 
olfactory disturbances in, 337 
orbital complications of, 346 
pathology of chronic, 328, 330 
prognosis of acute, 327 
of chronic, 348 

rhinoscopic examination in, 338 
Sluder’s method, 333, 354 
symptoms of chronic, 330, 337 
transillumination in, 339 
treatment of acute, 327 
of chronic, 332, 349 
suppurative, 349 
by auto-vaccination, 350 
by operation, 350 
X-ray in, 340 

Evolution of the external radical operation 
on the frontal sinus, 280 
Examination of the maxillary and frontal 
sinuses at various times after death, 
28 

of the nose for sinus disease, 1 
Exophthalmos, 99, 346 
Exploratory needle puncture of the maxil¬ 
lary sinus, 168 

Extension by contiguity cause of sinus dis¬ 
ease, 39 

External operation on the ethmoid cells, 
356 

on the frontal sinus, 278 
on the maxillary sinus, 190 
on the sphenoid sinus, 402 
Eye symptoms in accessory sinus disease, 
97 


F 


Faraci’s bone-cutting forceps for sphenoid, 
404 

Fever in sinus disease, 72 
Foreign bodies in the sinuses, 41 
Fossa, canine, 107 

opening maxillary sinus through, 
190 

Fovea ethmoidalis, 17, 305 
Freeman’s syringe, 182 




INDEX 


425 


Frontal bone, 15 

orbital plate of, 16 
sinus, 201 

absence of, 201 
anatomy of, 201 
anterior wall of, 203 
Beck’s osteoplastic resection of, 295 
blood supply, 212 
boundaries of, 203 
catheterization of, 248 
Citelli’s method of operating on, 296 
communication with nose, 206 
comparison of methods of operating, 
297 

dehiscence in walls of, 204 

development of, 23 

dilatation of the walls of, 258 

enclosed cell within, 206 

extent of normal, 202 

failure of one side, 202 

Good’s intranasal operation on, 274 

Halle’s intranasal operation on, 271 

hydrops of, 259 

indications for radical operation on, 
278 

inferior wall of, 203 
Ingals’s intranasal operation on, 
269 

irrigation of, 248 
Killian’s operation on, 281 
Knapp’s operation on, 285 
mucocele of, 258 
mucosa of, 212 
osteoplastic resection of, 293 
ostium of, 206 
posterior wall of, 204 
pyocele of, 259 

radical or modified Killian operation 
on, 286 

untoward results following, 299 
deaths following, 302 
relation to ethmoid labyrinth, 209 
to hiatus semilunaris, 208 
relative size and shape of, 202 
septa in, 204 
septum of, 202 
deviations in, 202 
sounding, 212 

difficulties encountered, 214 
technique of, 213 

superciliary ridges as clue to size, 
202 

syphilis of, 255 
thickness of walls, 203 
transillumination of, 252 
tuberculosis of, 255 
sinusitis, acute, 216 
aetiology of, 216 
of chronic, 237 

Beck’s osteoplastic resection for, 
295 

caries and necrosis in, 227 
caused by disease in neighboring 
sinuses, 209 
chronic, 237 
Citelli’s method for, 296 


Frontal sinusitis, complications in acute, 
227 

in chronic, 256, 259, 260 
paths of infection, 256 
deviation of the nasal septum in, 
217 

diagnosis of acute, 219 
of chronic, 247 
differential diagnosis, 253 
dilatation of anterior wall, 251 
dizziness and vertigo, 246 
external appearance of sinus in 
acute, 225 

external symptoms of, 250 
eye in acute, 223 
fistula formation in, 251 
general disturbances in, 251 
Good’s intranasal operation for, 274 
Halle’s intranasal operation for, 271 
headache in acute, 221 
in chronic, 241 

indications for external radical 
operation, 278 

Ingals’s intranasal operation for, 
269 

intracranial complications in acute, 
230 

treatment of, 230 
in chronic, 260 
diagnosis of, 262 
Killian’s operation for, 281 
untoward results, 299 
Knapp’s operation for, 285 
Lothrop’s operation for, 294 
nasal symptoms in acute, 224 
in chronic, 243 

oedema of upper eyelid in chronic, 243 
olfactory disturbances, 225, 244 
operations, comparative value, 277 
orbital complications in acute, 229 
in chronic, 259 
osteomyelitis in, 228 
pathology, 228 
symptoms, 229 

osteoplastic resection for, 293 
pain in the acute, 221 
in chronic, 241 
pathology of acute, 218 
of chronic, 239 
periostitis and ostitis in, 227 
pressure in sinus in positive, 238 
in negative, 239 
prognosis of acute, 226 
of chronic, 254 

radical or modified Killian opera¬ 
tion for, 286 
after-treatment, 292 
secretion in acute, 224 
in chronic, 243 
Sullivan’s rasps, 276 
tenderness in acute, 223 
in chronic, 242 

Thompson’s modification of Good’s 
operation for, 275 
transillumination in, 252 





426 


INDEX 


Frontal sinusitis, treatment of acute, 230 
of chronic, 262 
of operative, 233 
ultimate condition, 304 
X-rays in, 253 
Fronto-ethmoidal cells, 320 
Function of accessory sinuses, 25 

G 

Gastric disturbances due to sinus suppura¬ 
tion, 70 

General symptoms of sinus disease, 72 
Good’s operation on the frontal sinus, 273 
Griinwald’s forceps, 351 
Guisez’s external operation on the ethmoid 
labyrinth, 357 

H 

Hajek-Claus bone forceps, 198 

operation on posterior sphenoidal 
labyrinth, 355 

Hajek’s instruments for ethmoid, 350 
modified sphenoid punch, 412 
sphenoidal forceps, 404 
operation on ethmoid, 350 
Halle’s operation on the frontal sinus, 271 
Hartmann’s cutting forceps, 236 

operation on the frontal sinus, 281 
Headache in sinus disease, 54 
cause of, 55 
character, 56 
lack of constancy, 55 
localization, 57 
periodicity, 57 
variations in intensity, 57 
Hiatus maxillaris, 5 
semilunaris, 17 
atypical ending, 19 
topographical anatomy of, 17 
typical ending, 19 
Hoarseness, 69 
Huskiness of voice, 69 
Hyperplasias and hypertrophies of the nas¬ 
al mucosa as an setiological factor in 
causation, 38 

Hyperplastic ethmoiditis, 328 

I 

Indigestion due to sinus disease, 70 
Inferior meatus of nose, 3, 11 
turbinate, 5 

Influenza as an setiological factor, 35 
Infraction of middle turbinate, 2 
Infra-orbital canal, 108 
foramen, 108 
recess, 108 

Infundibular cells, 209 
Infundibulum, 19, 122 
Ingals’s operation on the frontal sinus, 
269 

Intellectual disturbances, 71 
Intracranial complications of sinus dis¬ 
ease, 98 
ethmoid, 348 
frontal, 230 


Intracranial complications, maxillary, 146 
sphenoid, 401 
Iris, changes in, 98 
Irrigation of sinuses, frontal, 248 
maxillary, 169 
sphenoid, 403 

J 

Jansen’s operation on the frontal sinus, 
280 

on the sphenoid sinus, 414 
K 

Killian nasal speculum, 2 
Killian’s operation on the frontal sinus, 
281, 298 

untoward results following, 299 
Knapp’s operation on the frontal sinus, 

285 

Krause-Mikulicz operation on the maxil¬ 
lary sinus, 180 

Krause’s operation on the maxillary sinus, 
172 

Kuhnt’s operation on the frontal sinus, 280 

L 

Lachrymal bone, 10 
Lamina cribrosa, 17 
papyracea, 16 
perpendicularis, 16 

Laryngeal affections as a symptom, 68 
Latent empyema, 54, 340 
Lateral wall of nose, 1, 3, 4 
Lichtwitz’s needle for puncture of maxil¬ 
lary sinus, 169 

Lining membrane of sinuses, 47 
Luc’s operation on the ethmoid labyrinth, 
3o3 

on the frontal sinus, 279 
M 

Maxilla, superior, 4 
Maxillary sinus, 107 

accessory ostium of, 9, 112 
aetiology of, disease of, 121 
teeth in, 123 

alveolar boundary of, 109 
anatomy of, 119 
anomalies of, 112, 114 
anterior wall of, 108 
blood supply, 119 

Caldwell-Luc method of operating 
on, 190 

capacity, of, 107 
caseous degeneration, 134 
catheterization of, 167 
cholesteatoma formation, 136 
closed empyema, 140 
contamination of, from overlying 
sinuses, 127 
cysts, 130 

Dahmer’s method of operating, 183 
dehiscences in walls of, 109 
Denker’s method of operating on. 





INDEX 


427 


Maxillary sinus, dentigerous cysts, 131 
development of, 22 
dimensions of, 107 
double, 117 

empyema in posterior half of, 397 
fistula in mouth following opera¬ 
tion, 199 
floor of, 109 
foreign bodies, 128 
interior of, 110 
irrigation of, 167 

Krause-Mikulicz method of operat¬ 
ing on, 180 

Krause’s method of operating on, 
172 

latent empyema, 130 
likened unto a pyramid, 107 
malignant tumors of, 129, 130 
mucocele of, 136 
mucoid cysts of. 130 
nasal wall of, 111 

relation to nasal structures, 
111 

needle puncture with lavage, 168 
through inferior meatus, 169 
through middle meatus, 173 
osteomyelitis of, 129 
ostium of, 9, 112 

relation of, to internal wall, 112, 
167 

over-development, 113 
partial septa in, 117 
polyps, 135 
posterior wall of, 108 
preturbinal method of operating on, 
187 

relation of floor to teeth, 109 
relative importance of walls, 107 
Kontgen ray, 142 

relation to lachrvmo-nasal canal, 
119 

roof of, 108 
sounding, 120, 167 
stone formation in, 136 
suction or negative pressure, 142 
superior wall, 108 
surgical anatomv of lateral wall, 
119 

symptoms of disease in, 143 
syphilis, 129 

transillumination of, 140 
value of, 141 
traumatism of, 128 
tuberculosis, 129, 130 
under-development of, 115 
X-ray in diagnosis, 142 
sinusitis, acute inflammation of, 143 
aetiology of, 121 
Caldwell-Luc method, 190 
after-treatment, 195 
modification of, 198 
under local anaesthesia, 194 
Canfield’s operation for, 185 
chronic, 147 

complications of, 146, 153 
of by cyst formation, 154 
of meningeal, 146 


Maxillary sinusitis, complications of orbi¬ 
tal, 146 

conservative treatment in, 167 
Cowper’s method in, 138, 178 
Dahmer’s method, 183 
after-treatment, 185 
diagnosis of, 73, 137, 154, 155 
differential diagnosis, 154, 155 
dilatation of antrum, 153 
general disturbances, 145 
indications for treatment, 155 
inferior nasal passage opening 
through, 180 
irrigation in, 172 
Krause-Mikulicz operation, 180 
advantages of, 182 
after-treatment, 181 
middle nasal passage opening 
through, 179 
mild case of, 147 
moderate case of, 147 
nasal symptoms of acute, 143 
of chronic, 147 
nasopharynx in, 151 
needle puncture technique, 168 
middle meatus, 173 
nervous manifestations in, 152 
olfactory disturbances, 152 
operative treatment for, 178 
choice of, 156 
orbital complications, 153 
preturbinal method, 187 
after-treatment, 188 
prognosis, 155 

radical operation, results of, 199, 
200 

causes of failure, 197 
secretion in, 144, 149 
severe case of, 148 
symptoms of acute, 143 
of chronic, 147 

syringing through ostium, 167 
teeth in, role of, 124 
treatment of, 171 

trocar through inferior nasal pass¬ 
age, 177 

untoward sequelae- following the 
radical operation, 199 
Maxillo-orbital cells, 321 
Meatus of nose, 3 
Meningitis, 101 
Middle nasal passage, 3, 11 
turbinate, 2 
cell in, 12 

in empyema of, 341 
infraction of, 233 
lamella of, 308 
removal of, 235 

Mosher’s operation on ethmoid, 353 
Mucocele of sinuses, 51 
ethmoidal, 342 
frontal, 259 
maxillary, 136 

Mucous membrane of nose, 21 
changes in, 47, 62 
of sinuses, 48 
Multiple sinusitis, 417 




428 


INDEX 


N 

Nasal discharge in sinus suppuration, 60 
floor, 3 
fontanelles, 10 
mucosa, 21 
polyps, 63 
passages, 3 
inferior, 11 
middle, 11 
superior, 12 
roof, 10 

speculum of Killian, 2 
spine, superior, 207 
wall, lateral, 4 

Nasofrontal duct, 206, 208, 308 
boundaries of, 208 
formation of, 207 
ostia of, 208 

Necrosing ethmoiditis, 329 
Necrosis of sinus walls, 257 
Needle puncture of maxillary sinus, 168 
Negative pressure as a means of diagnosis, 
84 

treatment, 88 
Nervous disturbances, 73 
Neuralgia in sinus disease, 56 
Normal mechanism of drainage, 26 
of frontal sinus, 27 
of maxillary sinus, 27 
of sphenoid sinus, 28 

0 

Obturator for maxillary sinus, 178 
(Edema of upper eyelid, 260 
Ogston-Luc operation on the frontal sinus, 
297 

Ogston’s operation on the frontal sinus, 
279 

Olfactory fissure, 12 

Optic nerve, relation of posterior ethmoid 
cells to, 323 

of sphenoid sinus to, 373 
Orbital complications of sinus disease, 97 
of ethmoid sinus, 346 
of frontal sinus, 229 
of maxillary sinus, 153 
of sphenoid sinus, 399 
symptoms of, 97 
those caused by pressure, 99 
by toxins, 100 

plate of maxillary sinus, 107 
Osteomyelitis of frontal bone, 228, 301 
Ostium in middle nasal passage, 12 
in olfactory fissure, 12 
in superior nasal passage, 12 
of accessory maxillary sinus, 9. 167 
of anterior ethmoid cells, 21, 310 
of frontal sinus, 20, 206 
of maxillary sinus, 9, 20, 112 
of posterior ethmoid cells, 12, 311 
of sphenoid, 12 

P 

Pain in sinus affections, 54 
Palate bone, 10 


Pansinusitis, 417 
Pars membranacea, 9 

Pathological changes in the mucous mem¬ 
brane of the sinuses, 47 
of chronic sinus disease, 49 
of differential diagnosis, 50 
of ethmoiditis, hyperplastic, 328 
of suppurative, 344 
of frontal, 218, 239 
of maxillary cysts, 130 
of sphenoidal, 372, 379, 380 
Pharyngeal affections as a symptom, 70 
Pharyngitis sicca, 68 
lateralis, 68 

Physiology of the accessory sinuses, 25 
of the ethmoid cells, 324 
Pneumonia as an etiological factor, 31, 35 
Polyps, choanal, 66 
formation of, 65 
relation of, to sinus disease, 63 
Posterior group of ethmoid cells, 311 
of sinuses, 12 

Postmortem examination of the accessory 
sinuses, 46 

Pre-ethmoidal recess, 311 
Preturbinal method of operating on the 
maxillary sinus, 187 

Privat’s syringe for subperiosteal injec¬ 
tions, 183 

Processus uncinatus of ethmoid bone, 7. 
121 

Psychical disturbances, 71 
Pterygoid process, 11 
Pus as a symptom of sinus disease, 60 
in middle nasal passage, 74 
in nasopharynx, 382 
in olfactory fissure, 76 
in superior nasal passage, 76 
Pyocele, 61 

R 

Radical operation on the ethmoid cells, 356 
on the frontal sinus, 286 
on the maxillary sinus, 190 
on the sphenoid sinus, 408 
Recessus spheno-ethmoidalis, 309 
Relation of floor of maxillary sinus to the 
teeth, 110 

of frontal sinus to anterior ethmoid 
cells, 209 

of sinuses to optic nerve, 92 
to brain, 92 
to orbital cavity, 92 
Retrobulbar neuritis, *100, 399 
Riedel’s method of operation on the frontal 
sinus, 281 

Role of the sinuses during respiration, 26 
Rontgen rays as a means of diagnosis, 81 
ethmoid sinus, 83 
frontal sinus, 81 
maxillary sinus, 83 
sphenoid sinus, 84 

S 

Scarlet fever as an etiological factor, 37 
Schleich’s anesthesia in intranasal opera¬ 
tions on the maxillary sinus, 194 






INDEX 


429 


Secretion in sinus disease, importance of, 
53 

purulent, in tlie nose, 60 
Septa in the frontal sinus, 204, 205 
in the maxillary sinus, 110, 117 
in the sphenoid sinus, 376 
Septum between frontal sinuses, 202 
between sphenoid sinuses, 374 
Sexual apparatus, 73 
Sinuses, anterior (first series), 2 
posterior (second series), 3 
Sinusitis e sinuitide, 42 
Sore throat as a symptom, 68 
Sphenoid sinus, 369 
absence of, 369 
anatomy of, 369 
anomalies of, 375 
anterior wall of, 370 
arterial supply of, 378 
capacity of, 369 
catheterization of, 393, 403 
Jacob’s method, 393 
compared to cube, 370 
enlarging ostium of, 404 
external wall, 374 
Grayson’s operation, 393 
Halle’s operation, 413 
indications for radical operation on, 
406 

inferior wall, 374 
irrigation, of 403 

Jansen’s method, 414 
mucosa of, 377 
mucocele of, 390 

operation on, through maxillary 
route, 414 
ostium of, 371 
diaphragmatic, 372 
over-reabsorption of. 367 
pars ethmoidalis. 375 
pars nasalis of, 371 
posterior wall of, 372 
radical operation on, 408 
after-treatment, 412 
relation to ethmoid capsule, 376 
to optic nerve, 373 
to pituitary body, 373 
septum of, 374 
absence of, 369 
deviation of, 368, 374 
sounding the, 391 
superior wall, 373 
veins of, 378 
sinusitis, 
acute, 378 
{etiology, acute, 378 
chronic, 380 

ultimate condition of operated 
sinus, 413 

cacosmia as a symptom of, 384 
chronic, 380 
complications of, 398 
process of infection, 399 
diagnosis of acute, 379 
of chronic, 38/ 
differential diagnosis, 394 
headache in chronic, 383 


Sphenoid sinusitis, histopathology of 
acute, 379 

of chronic, 380 

intracranial complications, 390, 401 
mental symptoms of chronic, 379 
nasal symptoms of chronic, 382 
objective symptoms of, 383 
ocular symptoms, 385 
pathology of acute, 379 
of chronic, 381 
prognosis of chronic, 397 
secretion in chronic, 384 
symptoms of acute, 379 
of chronic, 381 

throat symptoms of chronic, 382, 385 
treatment of acute, 380 
of chronic, 402 

use of Killian speculum in, 388 
Spheno-ethmoidal cell, 376 
empyema of, 397 
recess, 309, 371 
Spheno-palatine artery, 21 
Stone formation in maxillary sinus, 136 
Streptococci and staphylococci, 31 
Suction or negative pressure in sinus dis¬ 
ease, 84 

Superior nasal passage, 12 
turbinate, 309 
lamella of, 309 

Suppuration in sinuses, aetiology of, 34 * 
bacteriology of, 28 
diagnosis of anterior group, 73 
of posterior group, 76 
pathology of, 47 
Supreme turbinate, 13 
Surgical anatomy of the lateral wall of the 
nose, 119 

Symptoms of sinus inflammation, 54 
Syphilis as a causative factor, 39 

T 

Taptas’s operation on the frontal sinus, 281 
Teeth in relation to floor of maxillary 
sinus, 109 

Tenderness over sinus as a symptom, 59 
Thompson’s nasal scissors, 233 
Thomson’s modification of Good’s opera¬ 
tion on the frontal sinus, 275 
Thrombosis of cavernous sinus, 400 
mechanism of infection, 400 
treatment, 402 
Tic douloureux, 57 

Transillumination as a means of diagnosis, 
78 

in ethmoid cells, 339 
in frontal sinus, 252 
in maxillary sinus, 140 
Traumatism as an {etiological factor, 41 
Treatment of sinus disease, 86 
acute, 86 

by vaccine therapy, 91 
chronic, 90 

ethmoidal, 327, 332, 349 
frontal, 230, 232, 262 
maxillary, 167 
sphenoidal, 380, 391, 402 






430 


INDEX 


Trochlea, resection of, in operation on 
frontal sinus, 284 
Tuberculosis, 39 
Turbinates, inferior, 5 
middle, 2, 12 
superior, 12 
supreme, 13 

U 

Uncinate process, 7, 120 
cell in, 316 
lamella of, 307 
resection of, 266 


V 

Vaccine treatment of sinus disease, 91 
Verkasung (metamorphosis of secretion 
into cheesy mass), 52, 134 
Vertigo as a symptom, 70 

W 

Wagener’s antrum punch, 182 
Welhelmenski’s trocar, 180 

X 

X-rays as a means of diagnosis, 81 
maxillary sinus, 142 























































































































































































































































































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